Facility Evaluation Report

Licensing Program Analysts (LPA)'s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with Administrator Janette Lapitan.

LPAs toured the facility inside and out. LPAs observed adequate food supply. Smoke detectors and carbon monoxide detector were tested and are in working order.Fire extinguishers were serviced 7/10/25. Water temperature measured at 105 F. Facility was clean. Bedrooms had all appropriate furnishings. Facility bathrooms had skid mats and grab bars.

LPA's reviewed staff and resident records. Staff had current CPR/First Aid. Medications were reviewed.

LPAs observed the following deficiencies:

S1 did not have staff training. All staff did not have hospice or home health training for R1 and R2. R1 did not have a completed pre appraisal for R1. R1 did not have a home health care plan. R2 did not a hospice care plan . Medications were not being stored in their original containers. R2 had full bed rails with no physician order. Facility staff are injecting R1 with R1's prescribed medication. Facility does not have a sharps container to store used needles.

A copy of this report was provided with appeal rights and plans of correction.