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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the electronic Medication Administration Record (eMAR) for persons in care across four care units and observed that all medications were signed and coded for by staff for for July 1 to 6, 2026, as required by policy.

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

To Be Corrected By:

Observations:

Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure that all policies and procedures at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 1, 2026

Observations: Licensing audited the policies and procedures for the facility and observed that all required policies had not been reviewed in the past year.