Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care

Corrective Actions Required: Ensure that care plans are reviewed and, if necessary, modified when there is substantial change in the circumstances of the person in care. their care needs. 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 22, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: on July 1, 2025 the care plan for the person in care was updated to reflect medication refusal, on August 1, 2025, staff were provided training on person in care's rights and understanding of refusal protocols and compliance with doctor's orders, and when to update a care plan and ongoing random care plan review audits would be conducted to ensure accuracy. 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 June 13, 2025. Through the investigation process, Licensing determined that the care plan for a person in care did not address if the person in care refused medication.