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 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: December 3, 2025

Observations: Licensing observed four medications pre-poured at 10:00 a.m. for administration at 12:00 p.m. by a nurse that was off work at 11:00 a.m., and would not be administering these medications to persons in care.

Description: A licensee must keep the following records in respect of each employee: criminal record check results,

Corrective Actions Required: Ensure records of criminal record checks results are kept.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Licensing reviewed ten staff files and five staff had criminal record check results that expired in May, June and August 2025.

Description: A licensee must keep a record respecting complaints made and concerns expressed to the licensee under section 60 [dispute resolution], and the responses to them.

Corrective Actions Required: Ensure there is a record respecting complaints made and concerns expressed to the licensee and the responses to them.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 31, 2025

Observations: Licensing did not observe a complaint log in place. The Manager stated there was no complaint log system in place.