Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing toured one person in care's bedroom and bathroom, and observed the bathroom flooring had been replaced.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A licensee must ensure that all rooms and common areas are maintained in a safe and clean condition.

Corrective Actions Required: Ensure that all rooms and common areas are maintained in a safe and clean condition.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 27, 2026

Observations: Licensing toured four person in care's bedrooms and bathrooms. Three person in care's bedrooms and bathrooms were in an unclean condition with significant dirt throughout the flooring.

Description: Despite subsection (1), a licensee may accommodate 2 persons in care in a bedroom if the bedroom is screened in a manner that is sufficient to ensure the privacy and dignity of each occupant,

Corrective Actions Required: Ensure that if two persons in care are accommodated to share one bedroom, that the bedroom is screened in a manner that is sufficient to ensure the privacy and dignity of each occupant.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 10, 2026

Observations: Licensing observed two persons in care being accommodated in one bedroom. The bedroom was not screened in a manner that was sufficient to ensure the privacy and dignity of each occupant.

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.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 11, 2026

Observations: Licensing audited three person in care's Medication Administration Records (MARs), dated May 2026 and two person in care's MARs did not include PRN medication results. In addition, the Narcotic Count Record dated May 2026 had multiple dates, that did not include a second staff signature for counting. Both processes were required by the policies and procedures of the medication safety and advisory committee.

Description: A licensee must have a plan that sets out how persons in care will continue to be cared for in the event of an emergency.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed the facility's emergency plan which included how persons in care would continue to be cared for in the event of an emergency.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

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:

Corrective Actions Taken By Licensee: Licensing audited the facility policy and procedures, and all were reviewed in the past year.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

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 each person in care's care plan is reviewed at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 11, 2026

Observations: Licensing audited three person in care's care plans. All three care plans had not been reviewed in the past year and one person in care's nutrition care plan was last reviewed in 2024.