Description: A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care,

Corrective Actions Required: Ensure that the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs 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 June 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: If a person in care came from community setting, there would be a question included at admission regarding the use of any special medical equipment moving forward. 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: July 18, 2025

Observations: Regarding intake April 4, 2025. Through the investigation process, Licensing determined that staff training had not met the needs of persons in care in relation to a Bilevel Positive Airway Pressure (BIPAP) machine.

Description: A licensee must ensure that if changes in the directions for use of a medication are made by a medical practitioner or nurse practitioner, the changes are promptly recorded on the person in care’s medication administration record,

Corrective Actions Required: Ensure that if the directions for use of a medication are changed by a medical practitioner or nurse practitioner, that the changes are promptly recorded on the person in care's medication administration record. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: By June 20, 2025, a memorandum was to be signed by all nursing staff regarding ensuring all new orders of medications were reflected in the Medication Administration Record (MAR) as soon as possible. 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: July 18, 2025

Observations: Regarding intake April 4, 2025. Through the investigation process, Licensing determined that a medication change was not promptly recorded on the medication administration record.

Description: A licensee must do all of the following:(b) operate the community care facility in a manner that will promote 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 June 5, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: On June 20, 2025, a memorandum was to be signed by all nursing staff regarding ensuring all new orders of medications were reflected in the Medication Administration Record (MAR) as soon as possible. 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: July 18, 2025

Observations: Regarding intake April 4, 2025. Through the investigation process, Licensing determined that a person in care's medication orders were not updated and medications were still offered or documented as refused by the person in care.