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 advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: February 20, 2025

Observations: Licensing audited the Medication Administration Record (MAR) for one person in care for January and February 2025. The MAR had medications that were not signed or coded for by staff. The Manager stated that the medications were discontinued and being updated. The Medication Safety Advisory Committee (MSAC) policies indicated that the MAR had to be updated by pharmacy when there was changes in medications.