Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure that policies and procedures are reviewed , and revised if necessary, at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 10, 2024

Observations: Licensing reviewed the facilities policy and procedure manual. All the policies were last reviewed in 2022.

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 that each person in care is weighed at least once a month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 10, 2025

Observations: Licensing audited three person in care's weight records for 2024. One person in care's weight was not recorded in June 2024.