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

Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 11, 2026

Observations: Licensing toured four person in care's bedrooms and bathrooms, and observed one person in care's bathroom had flooring removed in one section of the floor.

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: Ensure that a plan sets out how persons in care will continue to be cared for in the event of an emergency.

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 the facility's emergency plan which included evacuation procedures. The plan did not include how persons in care would continue to be cared for and/or relocated, in the event of an emergency.

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 the policies and procedures are reviewed, and if necessary revised, 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 the facility policy and procedures, and multiple policies were not reviewed in the past year.

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.