Facility Evaluation Report

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management related to a recent incident where a resident was able to consume another resident's medication. LPA met with administrative assistant Krystal calderon to explain the purpose of the visit.

Met with staff relevant to the incident for an interview.

At the time of the incident the facility did have a crush order on file for the med(dated 1/20/26), at the time of the incident the facility did not have a signed written consent form from responsible party about camofaluging the medication. Per the interview with the staff, the facility has other clients who are reciving crushed/camoflauched medication, LPA gave guidance that consents should be audited and updated as necessary.

LPA was given a copy of the training that the facility gave as a part of thier own internal process for resolving the inccident. Per the care coordinator, one of the two medications has been switched to a liquid form.

Citations were issued as apart of the visit. A Copy of the report was left the the administrator, LPA sent a copy of the best practices for Medication dispersal to the care coordinator. Exit interview was conducted