complaint·August 31, 2021

Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with Staff, Administrator, and R1’s Responsible Party (RP). Through documents reviewed, CCL noted R1 had a prescription for Seroquel 25mg oral tab. The Physician’s orders stating, “Take 1 tablet orally once daily at dinner as needed for agitation”, dated February 5, 2020. Through facility documents, CCL noted eight (8) times the medication was provided to R1 between October 2020 and April 2021 by S2 outside of prescribed time, all being prior to 4:00p.m. Documents show the prescription being provided on 10/14/20 @ 10:45a.m.; 11/23/20 @ 8:45a.m.; 2/10/21 @ 3:47p.m.; 3/4/21 @ 11:25a.m.; 3/17/21 @ 9:44a.m.; 3/30/21 @ 1:12 p.m.; 4/4/21 @ 8:01a.m.; and 4/15/21 @ 8:19a.m. When interviewing staff, CCL was informed R1’ schedule was to eat dinner at 5:00p.m. but the medication was provided prior to that time in order to control R1’s aggressive behaviors when assisting with ADLs. Interviews with S2 indicated they were aware of the physician’s orders stating the prescription was to be provided after dinner, but continued to provide R1 with the Seroquel outside of prescribed time. Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of “Medications not administered as prescribed by physician” to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies are being cited on 9099-D, per Tittle 22 regulations: 87465(a)(5)- Incidental Medical and Dental Care.. Exit interview conducted with Andrea Armstrong (Admin). LPA provided admin with a signed copy of the report, along with the 9099-D. Appeal rights provided. Throughout the course of the investigation, CCL conducted interviews and reviewed documents. Interviews were conducted with Staff, Administrator, and R1’s Responsible Party (RP). Through interview conducted, CCL learned that R1 was not a fall risk, and staff were near R1’s room when the fall occurred. CCL was informed that staffing was adequate the morning of the fall, and R1 was regularly monitored by caretakers. CCL was unable to determine that R1’s fall was due to lack of care and supervision. Documents reviewed indicated R1 was not a fall risk at facility, and was ambulatory, not requiring a one on one assist. Although R1 was provided Seroquel the morning of the fall, outside of prescribed time; CCL is unable to determine R1’s fall was caused by the medication being administered outside of physician’s orders. Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of Facility’s lack of care and supervision resulted in resident’s fall to be UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. A copy of this report was left at facility for review.