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 all 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: April 10, 2026

Observations: Licensing audited two person in care's Medication Administration Records for March 2026. Licensing observed one person in care's noon medication had not been signed and/or coded for by staff on multiple dates in March 2026.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy the person in care is no longer taking the medication

Corrective Actions Required: Ensure that a person in care's medication is returned to the dispensing pharmacy if the person in care is no longer taking the medication.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: April 10, 2026

Observations: Licensing audited the facility's medication cabinet and observed one person in care's medication had expired September 2025. The Manager stated the person in care no longer required this medication.