Facility Evaluation Report

Licensing Program Analyst (LPA) Rankin arrived to conduct an annual continuation visit at 9:27 a.m. LPA met with Alexandria Neal, Clinical Director and Designee following review of medication and interviews.

LPA briefly observed physical plant, conducted interviews with clients who were willing to speak, spoke with available staff and reviewed medications. During time of visit LPA noted clients were sleeping, or participating in a group activity.

MEDICATION: A sampling of medications was reviewed, all cabinets within the medication room are locked at all times unless cabinet is in use. Medication Administration Records (MARs) and Centrally Stored Records are maintained for all clients. Controlled substances are counted each shift, destruction records and PRN Authorization and use records are maintained. LPA reviewed medication on initial visit 6/12/26, questions about records arose, LPA re-reviewed medication and records with lead LVN during return visit, updates will be done with all staff regarding the purpose and proper documentation of Start Dates, Intake Quantities when clients first arrive, and PRN notations. Counts were made on additional clients medications during this return visit, counts were correct, records were correct, no expired medications were noted, and doctors’ orders were available.

Exit interview conducted, and a copy of this report given.