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 promotes the health, safety and dignity of persons in care. Specifically, that required documentation is completed. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On October 29, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that all nursing staff were to follow the Fall Management and Prevention Program policy, the management team was to review the Risk Management for ninety days to ensure the fall policy was followed and all documentation was complete and coaching then progressive discipline would follow for any non-compliance. 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: January 29, 2026

Observations: Regarding intake dated September 17, 2025. Through the investigation process, Licensing determined that post fall documentation was not completed.