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: February 6, 2023

Observations: Licensing toured the facility and observed damage to the hallway walls and a person in care's room on the sixth floor.

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 comply with 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: January 6, 2023

Observations: Licensing audited the Narcotic Count binders on three units. There was no narcotic count completed on November 29, 2022 at 1500hrs on the Crofton unit. On November 27, 2022 and Dec 7 and 22, 2022, there was only one nurse signature when two staff are required to co-sign. Licensing audited the Medication Administration Record (MAR) for persons in care on three units. One person in care had 2100hr medication not signed for or coded by staff on January 4, 2022 and one person in care had medications not signed for or coded by staff on January 6, 2022. Licensing observed a medication in it's original packaging, dated January 5, 2022 at 2000hrs in the medication cart for a person in care which was signed for as administered on the Medication Administration Record.

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required: Ensure that all staff have a current record of a Criminal Record Check on file.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 6, 2023

Observations: Licensing audited 27 staff files. Two staff did not have a current record for a Criminal Record Check on file.

Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,

Corrective Actions Required: Ensure that all staff are compliant with the Province's immunization and TB programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 6, 2023

Observations: Licensing audited 27 staff files. One staff had no record of TB.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care

Corrective Actions Required: Ensure that each care plan is reviewed, and if necessary, modified if there is a substantial change in the circumstances of the person in care.

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By: January 13, 2023

Observations: Licensing audited 22 person in care's care plans. Four persons in care had missing/wandering addressed in their care plan but were no longer a risk for missing/wandering.

Description: A licensee must ensure that all medications in the community care facility are safely and securely stored.

Corrective Actions Required: Ensure that all medications in the community care facility are safely and securely stored.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 6, 2023

Observations: Licensing toured the facility and observed medicated creams in multiple person in care's rooms.