Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

Corrective Actions Required: Ensure that the community care facility is operated in a manner that will promote the health, safety, and dignity of persons 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 November 18, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: On November 18, 2025, a reminder was sent to all Registered Care Aides (RCAs) related to documentation of Activities of Daily Living (ADLs), specifically related to bowel records and on November 17, 2025, education was provided to the fourth-floor care staff specifically addressing ADL documentation expectations. 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: December 19, 2025

Observations: Regarding intake dated September 15, 2025. Through the investigation process, Licensing determined that the Licensee did not operate the community care facility in a manner that promoted the health, safety, and dignity of persons in care. Specifically related to documentation.

Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer

Corrective Actions Required: Ensure that if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On November 18, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: On November 10, 2025, follow-up was completed with the staff who was responsible for submitting the September 22, 2025, unexpected illness Incident Report to Licensing. 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: December 19, 2025

Observations: Regarding intake dated September 15, 2025. Through the investigation process, Licensing determined that the licensee did not immediately notify a medical health officer, in the form and in the manner required by the medical health officer, about a reportable incident.