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 all employees comply with the medication safety and advisory committee policies and procedures.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 28, 2023

Observations: Licensing observed four open bottles of liquid medication sitting on the counter in the medication room. The nurse stated that the medication bottles were open partially for an earlier administration and partially for later administration. Licensing observed the narcotic count sheet for July 2023 and observed the nurse had pre signed the evening count for July 28, 2023. The nurse also pre signed narcotic administration at 10:45 a.m. on July 28, 2023 for a 12:00 p.m. medication.

Description: A licensee must ensure that meals are provided by ongoing room tray service, if reassessed by the person in care’s medical practitioner or nurse practitioner at least once every 30 days

Corrective Actions Required: Ensure reassessments are completed at least every 30 days for food tray service.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 29, 2023

Observations: Licensing observed one care plan that had food tray service and the last reassessment was conducted in March 2023 by the dietitian.

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 if a person in care has been determined to be at risk of falls, that they have a fall prevention plan that includes a plan to follow up on any 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: August 29, 2023

Observations: Licensing reviewed three care plans with fall care plans and two fall plans did not have a plan for falls suffered.

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required: Ensure weights are completed monthly.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: August 29, 2023

Observations: Licensing reviewed three person in care's files and two files did not have weights competed for January, April and June 2023.