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

Corrective Actions Required: Ensure all rooms/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: December 18, 2023

Observations: Licensing toured the facility and noted damage to the walls in multiple areas throughout the facility.

Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: character references in respect of the person

Corrective Actions Required: Ensure that character references are collected for each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 18, 2023

Observations: This contravention was brought forward from a Routine Inspection dated November 28, 2022. Licensing reviewed 16 staff files. Three staff files had no reference checks and one file had only one reference check.

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 staff follow the policies and procedures of the medication advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: October 18, 2023

Observations: Licensing audited the medication room and cart and observed a pre-poured medication, in a medication cup in the cart. Licensing also audited the medication administration record and observed one person in care did not have their medication signed for or coded by staff on October 9, 2023 at 2000hrs.

Description: Clear and up to date records of immunization status kept for each person in care

Corrective Actions Required: Ensure clear & up to date records of immunization status are kept for each person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 18, 2023

Observations: Licensing reviewed 16 person in cares charts and 13 persons in care did not have a record of immunization.

Description: A care plan must include all of the following: a plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment

Corrective Actions Required: Ensure that if a person in care has an agreement to the use of a restraint, that they have a restraint care plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: October 25, 2023

Observations: Licensing reviewed 16 persons in care's care plans. One person in care, who used a pin lock lap belt restraint did not have a restraint care plan.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care

Corrective Actions Required: Ensure that in the case of a person who is prone to falling, that they have a fall prevention plan which includes a plan to follow up on falls suffered by the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 1, 2023

Observations: Licensing reviewed 16 person in cares care plans and noted nine persons in care did not have a plan to follow up on falls suffered by the person in care.