Facility Evaluation Report

Licensing Program Analysts (LPA)'s Daiquiri Boyd and Shawna Doucette arrived at the facility unannounced to conduct a case management for an incident that occurred on 5/5/25. LPA's met with Administrator Nicole Morehead.

LPA's interviewed the Administrator. R1 had a prescription for .25 ml of morphine. and facility received 1 ml. of morphine. Facility logged into the centrally stored log they received .25 ml. Facility administered the 1 ml for 4 days totalling 6 doses. The dates administered 5/2/25 at 8 PM to 5/5/25 8 AM. Facility did not have an order to administer 1 ml every 12 hours to R1.

Facility did not have R1's PRN logged as received for 1 ML of morphine on the centrally stored log. Facility centrally stored log showed .25 ML

Facility noted on MARS log they administered .25 ml when they actually administered 1 ml.

An exit interview was conducted with the Administrator and a copy of this report was provided with appeal rights and plan of correction.