Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 31, 2025

Observations: Licensing reviewed several Medication Administration Records (MARs) and observed two PRN (as needed) records that stated "TBD" as the follow up outcome assessment which was not indicated in policy.

Description: A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care,

Corrective Actions Required: Ensure that there are emergency plans and procedures to prepare for, mitigate, respond to, recover from and evacuate persons in care in the event of an emergency.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 28, 2025

Observations: Licensing observed the facility emergency plan/procedures that included only fire emergency procedures.