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: July 4, 2024

Observations: Licensing audited the Medication Administration Record (MAR) and observed the medications for three persons in care were not signed or coded for by staff on multiple dates and times. In addition, Licensing audited the narcotic count records, and observed that there were no staff signatures for the third floor for June 13, 16, 22, and 30, 2024, as well as no staff signatures for the first floor for June 13, 14, and 23, 2024 as required by policy.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: July 4, 2024

Observations: Licensing audited the medication carts on three care floors, and observed that there were two expired medications on the third and sixth floors.