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, 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. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 30, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: the Licensee would create a protocol for off-duty nursing responsibilities by June 30, 2025, for any emergencies involving persons in care, Registered Care Aides (RCAs) were to call 9-1-1 and the Nurse could be contacted by phone when off-duty on an on-call basis for any concerns, questions, or guidance, RCAs did not have the training or scope to conduct nursing assessments, and the policy was updated in March 2025 to have vital signs as a nursing staff tasks, RCAs would no longer take vital signs of persons in care, a list of RCAs with medication administration training certification would be completed by June 15, 2025, Nurses would observe and review each RCA's medication administration practices and provide targeted medication administration training by June 30, 2025, and the Licensee would offer additional medication administration training. The corrective action plan was reviewed and accepted by Licensing. On January 29, 2026, Licensing conducted a Complaint Follow Up Inspection and was informed by the Manager that the medication administration training for RCAs was in process. During an inspection on July 27, 2026, Licensing was informed by the Manager that the medication administration training for RCAs remained in process but was near completion.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 25, 2025

Observations: Regarding intake dated March 14, 2025. Through the investigation process, Licensing determined that the employees on duty were not sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care.

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 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 May 30, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: Room and safety check procedures were implemented in November 2024, and the shift task-list for staff included completion of the room and safety checks each shift with documentation of those checks, a Nurse would review the room and safety check sheets and communication binder charting from previous shifts and would follow-up on any missed documentation by writing in the staff communication book, the Care Plan for a person in care was updated related to room and safety checks, and highlighted their suicidal ideation risk, communication was provided to staff on May 30, 2025, to review the person in care's updated Care Plan, and a reminder to perform and document room and safety checks every shift. The corrective action plan was reviewed and accepted by Licensing. On January 29, 2026, Licensing conducted a Complaint Follow Up Inspection and audited the Room Check Logs for January 2026, which were not all signed or coded as completed. During an inspection on July 27, 2026, Licensing audited the Room Check Logs for July 2026, and observed that they were not all signed or coded as completed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 25, 2025

Observations: Regarding intake dated March 14, 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.