Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.

Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: September 20, 2023

Observations: Licensing tested the water temperature for nine person in care's bedroom sinks. Three of the person in care's bedroom sinks had a water temperature reading of 50 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A verbal plan for corrective action was submitted to Licensing on September 20, 2023, by the Manager. The Manager stated maintenance was adjusting the hot water on this date and a log checking water temperature daily would be completed for a week. Full compliance will not be achieved until the plan has been implemented and completed.

Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: October 20, 2023

Observations: Licensing toured the facility and observed damage and scrapes on the walls in bedrooms and hallways.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: September 20, 2023

Observations: Licensing audited the narcotic count records on the first and second floor. There were eight second signatures missing from the narcotic count records. The Director of Care stated that two staff were required to sign the narcotic count records each shift.

Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable

Corrective Actions Required: Ensure that the consent for a person in care to be admitted or continued to be accommodated in a Community Care Facility, is given in accordance with Section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or Section 50.1 of this regulation.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: October 4, 2023

Observations: Licensing audited 15 person in care's records. One person in care did not have a record of consent to be admitted on file.

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required: Ensure that each person in care's records contains consent to call a medical/nurse practitioner or ambulance in the case of accident or illness.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: October 4, 2023

Observations: Licensing audited 15 person in care's charts. Two person's in care did not have written consent to call a medical/nurse practitioner or ambulance in the case of accident or illness.