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 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 5, 2022

Observations: Licensing observed the December 1, 2021, 2000 hour Dilaudid medication for person in care was not double signed by nursing staff.

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

Corrective Actions Required: Ensure persons in care have clear and up to date records of immunization status.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 5, 2022

Observations: Licensing observed four persons in care's files and two files did not have clear and up to date records of immunization status.

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 person in care to be admitted into a community care facility has written consent.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 5, 2022

Observations: Licensing observed four persons in care's files and two files did not have written consent for admission to the community care facility.

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 each person in care is weighed monthly.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 5, 2022

Observations: Licensing reviewed four persons in care's weight charts from August to November 2021 and one person in care was missing November weight.