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: On May 8, 2026, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a review of the MOST document and the expected storage of the document was to be reviewed by all nursing staff, pharmacists, and physicians in relation to the policies and procedures by June 10, 2026. Licensing reviewed and accepted this corrective action plan.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: May 8, 2026

Observations: Regarding intake February 19, 2026. Through the investigation process, Licensing determined that the licensee did not ensure that policies were implemented by employees, specifically related to Medical Orders for Scope of Treatment (MOST) forms.