Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair

Corrective Actions Required:

Corrective Actions Taken By Licensee:

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations: Licensing toured the facility on this date. All person in care's bedrooms were maintained in a good state of repair.

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 advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 8, 2024

Observations: Licensing audited the electronic medication administration record for persons in care from December 2 to 7, 2023. On December 5, 2023, there was one person in care who had no medications signed as administered for their 1900hr and 2000hr medications. The Medication Safety Advisory Committee policies indicate signing for medications once administered.