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 to operate the community care facility in a manner that will promotes 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 July 11, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: between July 11 and August 31, 2025, staff were to be trained on care planning, task and Kardex planning and the use of wound care documentation tools, with random audits to ensure compliance and on October 14, 2025, training outcomes would be reviewed with 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: August 15, 2025

Observations: Regarding intake dated July 11, 2025. Licensing determined that the licensee did not operate the facility in a manner that promoted the health, safety, and dignity of persons in care. Specifically, related to Electronic Medication Administration Record (eMAR) documentation.

Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.

Corrective Actions Required: Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On July 11, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: between July 11 and August 31, 2025, staff were to be trained on safe transfers, mobility devices, and care planning, with random audits to ensure compliance, from August 5 to September 12, 2025, Health Care Aides (HCAs) were to complete all education and pass a competency review to demonstrate safety and person-centered care. 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: August 15, 2025

Observations: Regarding intake dated July 11, 2025 . Through the investigation process, Licensing determined that the care plan for a person in care had not been implemented when transporting the person in care, which resulted in an injury.