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 employees comply with the policies and procedures of the medication safety and advisory committee. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 3, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Medication Administration procedures and guidelines was reviewed on April 11, 2025 with all nurses and an email reminder would be sent to nurses by November 10, 2025 and a new procedure for "Medication Dispensing for Temporary Absences from Long Term Care" policy would be completed and sent to staff for review by January 13, 2026. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 5, 2025

Observations: Regarding intake September 17, 2025. Through the investigation process, Licensing determined that medication was left unsupervised after dispensed and that there was unchecked medication dispensed for social leave which did not follow the medication safety and advisory committee policies.

Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

Corrective Actions Required: Ensure that the facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 3, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: staff education and care plan audit would be completed by December 4, 2025 to ensure documentation of care, including checklists for specific circumstances, was completed, and refusals or changes reported to nursing staff. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 5, 2025

Observations: Regarding intake dated September 17, 2025. Through the investigation process, Licensing determined that staff did not consistently document completed care for persons in care.

Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer

Corrective Actions Required: Ensure that if a person in care is involved in a reportable incident, that the licensee immediately notifies a medical health officer, in the form and in the manner required by the medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 3, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a new tracking form for reportable incidents was created and would be in use by December 1, 2025 and ongoing. The corrective action plan was reviewed and accepted by Licensing.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 5, 2025

Observations: Regarding intake dated September 17, 2025. Through the investigation process, Licensing determined that the licensee did not immediately notify a medical health officer of a reportable incident.