Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care

Corrective Actions Required: Ensure that a person in care's care plan is modified when there is a substantial change in the circumstances of the person 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 September 25, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a person in care's care plan was updated to include a detailed bowel and bladder care routine, and a notice and the updated care plan was posted in the administrative staff area, directing all staff to review the care plan. 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: October 31, 2025

Observations: Regarding intake September 9, 2025. Through the investigation process, Licensing determined that a person in care's care plan had not been modified when there was a substantial change in the circumstances of the person in care.