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: September 16, 2025

Observations: Licensing audited several Medication Administration Records (MARs) and observed multiple instances where PRN (as needed) medication effectiveness was not being recorded.

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:

Corrective Actions Taken By Licensee: Licensing observed the facility emergency plan/procedures binder with procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.

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

To Be Corrected By:

Observations: Licensing observed the facility emergency plan/procedures binder with procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.