Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure that policies are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: Between June 26, 2026 and July 9, 2026, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included: A review of the policy with Nursing was to be completed by July 14, 2026, the Skin and Wound Assessment Team has reviewed all current wounds, all NSWOC wounds are to be reviewed weekly with the Licensed Practical Nurse (LPN) and documented in the person in care chart as well as in a wound round report and any changes to the wound care plan are to be done by SWAT which includes communication with the physician. 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: September 30, 2026

Observations: Regarding intake May 8, 2026. Through the investigation process, Licensing determined that the wound management policy had not been implemented by employees.

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: Between June 26, 2026 and July 14, 2026, the Licensee submitted a corrective action plan to Licensing. This corrective action plan included: wound care education for Nursing staff was started and will be provided over two months to accommodate schedules and would be completed by September 30, 2026, wound care binders have been placed at each nursing station, NSWOC orders are to be placed in the binders and a copy in the person in care's chart and the Assistant Care Manager is to audit all person in care records for step-by-step wound care documentation. 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: September 30, 2026

Observations: Regarding intake May 8, 2026. Through the investigation process, Licensing determined there was a lack of documentation related to the wound care that had been provided.