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

Corrective Actions Required:

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 17, 2023

Observations: Licensing audited three employee files and observed three employee performance reviews were dated May 2020, February 2022 and August 2022. The performance review policy indicated performance reviews were completed quarterly.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan

Corrective Actions Required: Ensure that each care plan is reviewed and if necessary modified, at least once a year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 17, 2023

Observations: Licensing reviewed two person in care's care plans. Both person in care's nutrition care plans were dated 2021.