Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure policies are implemented by employees, specifically related to performance review policies.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 28, 2023

Observations: Licensing audited three employee files and observed one file had a performance review last completed July 2022. The facility policy was to complete reviews ever three months.

Description: A care plan must include all of the following: a nutrition plan that assesses a person in care’s nutrition status,

Corrective Actions Required: Ensure a care plan includes a nutrition plan that assesses a person in care's nutritional status.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 28, 2023

Observations: Licensing audited two person in care's care plans and observed one care plan did not include a nutrition 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 a fall care plan includes a follow up to any falls suffered by a person in care, if the person in care is identified as prone to falling.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 28, 2023

Observations: Licensing audited two person in care's care plans, and both fall care plans did not include a follow up plan to falls suffered by the person in care.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan

Corrective Actions Required: Ensure that a care plan is reviewed, and if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once a year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 28, 2023

Observations: Licensing audited two person in care's care plans and both oral care plans were last reviewed August 2021.

Description: A licensee must keep the following records in respect of each employee: character references,

Corrective Actions Required: Ensure that character references are kept in respect of each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 28, 2023

Observations: Licensing audited three employee files and observed one file did not include character references in respect of the employee.

Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care

Corrective Actions Required: Ensure there is an ongoing planned program of physical, social and recreational activities suitable tot he needs of the persons in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 28, 2023

Observations: Licensing observed the facility's January 2023 calendar of recreation activities, which was half completed.