Facility Evaluation Report

Licensing Program Analyst’s (LPAs) Micheal Bilger and Noel Wolf Petersen arrived unannounced for a Case Management regarding two incident reports on 4/16/25. LPAs met with the assistant administrator and explained the purpose of the visit, and the administrator was informed of the presence of licensing.

On March 10 th 2025 at 5 pm, Staff 1(S1) observed that three medications for Resident 1(R1) were unadministered as prescribed. Upon discovering the medication discrepancy S1 reported the error to the assistant administrator and administrator. The prescribing doctor was contacted for instructions regarding the missed doses. S1 was on the shift where the medication error occurred. S1 acknowledges the error in administering the medication. S1 has Direct Support Personnel 1&2 certification, training specific to medication dispersal prior to the error, and no previous incidents of medication procedure errors in the past year. The administrator reported the incident to CCL and regional center 3/10/25.

LPA has observed that medication training for S2 has taken place since the incident, and all clients MAR logs and bubble pack medication doses are currently in order.