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: August 18, 2026

Observations: Licensing audited the Medication Administration Record (MAR) for August 2026, and observed that one medication was not signed or coded for by staff on August 1, 2026, and two medications were not signed or coded for staff on August 14, 2026, as required by policy.

Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure that policies are implemented by employees.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 18, 2026

Observations: Licensing audited three staff files and records and observed that two staff did not have performance reviews completed in the past year, and kept on file, as per policy.

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required: Ensure that each person in care has consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness, kept on file.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: September 18, 2026

Observations: Licensing audited the care plans and records for two persons in care and observed that both persons in care did not have consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness, kept on file.