Facility Evaluation Report

On 02/17/2026 at 10:15 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding incident reports received by the Community Care Licensing Division (CCLD) on 01/07/2026. LPA met with Assistant Executive Director Deborah Bradley and Executive Director Specialist Kelly Reynolds and explained the purpose of the visit.

LPA received an Unusual Incident Report (UIR) regarding an incident that occurred on 01/03/2026 indicating that Staff (S1) administered a narcotic medication dose to Resident (R1) at approximately 7:49 AM and administered another dose of the same narcotic medication at 8:36 AM. LPA reviewed R1’s physician’s orders, Medication Administration Record (MAR) for January 2026, and narcotic log. Documentation indicates the medication hydrocodone/APAP 5/325 mg tablet was ordered to be administered as one tablet twice daily, every four hours. The UIR indicated R1 refused the evening dose.

The UIR further documented that on 01/04/2026, Staff (S2) notified Staff (S3) that R1 had been administered two doses of the medication that morning. Administrative review identified duplicate medication orders within the facility’s QMAR system.