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 employees follow 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: January 29, 2024

Observations: Licensing observed seven narcotic PRN blister packages that appear to have broken seals on different dates. One blister package had handwriting on three different days indicating the medication was borrowed for another person in care.

Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address an assessment of the nature of the risk of falling presented by the person in care

Corrective Actions Required: Ensure a care plan includes a fall risk.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 29, 2024

Observations: Licensing observed seven care plans and observed two care plans that did not have a fall risk assessment.

Description: A care plan must include all of the following: if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan to prevent the person in care from leaving

Corrective Actions Required: Ensure persons in care who are at risk of going missing, have a care plan to locate the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: January 29, 2024

Observations: Licensing observed seven person in care's care plans and two care plans did not have missing/wandering plans for persons in care that were at risk of going missing.