Facility Evaluation Report

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Barbara Fleck during today's inspection.

LPA arrived to review an incident report received by the facility. On 6/13/26 medication technician(med tech) gave a hospice resident (R1) the wrong amount of medication. Hospice prescribed R1 1ml of morphine every 1 hour, and med tech gave R1 2ml of morphine every 1 hour for 7 doses. Family and hospice were notified of the medication error and resident was monitored. Administrator reported med tech no longer works at the facility and training was completed for all staff dispensing medication.

Copy of report and appeal rights provided.