Description: A licensee must ensure that meals are provided by ongoing room tray service, if by ongoing room tray service, if indicated in the care plan of a person in care,

Corrective Actions Required: Ensure that if a person in care is receiving meal service by ongoing tray service, it is included in the care plan of the person 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 October 8, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included an audit of care plans was completed for all persons in care receiving tray service and care plans were updated accordingly. 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: November 20, 2025

Observations: Regarding intake September 5, 2025. Through the investigation process, Licensing determined that the care plan for a person in care had not included ongoing room tray service.