Facility Evaluation Report

On 12-13-22 at 1:00pm, Licensing Program Analysts (LPA'S) Kesha Lewis and Albert Johnson arrived unannounced to conduct a quarterly visit. LPA'S met with Administrator and explained the purpose of the visit.

7. Facility observation to ensure compliance and safety

Based on records review there are multiple areas that have missing information. At this time LPA'S are recommending a referral to (TSP) Technical support program be made.

Based on LPA'S records review there are multiple medication errors for R1 and the Shift count narcotics logs is not signed on multiple days. (copies taken). There are outdated needs and services plan and missing medical assessments.