Incident investigation·April 27, 2023

Licensing Program Analysts (LPAs) Vincent Moleski and Ruth Wallace arrived unannounced for a case management visit regarding an incident report received by licensing. LPAs Moleski and Wallace met with the administrator and explained the purpose of visit. The incident report stated that R1 had not been given medication in accordance with doctor's orders. LPAs Moleski and Wallace reviewed R1's MARs for March and April, two doctor's orders for R1, and centrally stored medications for R1. LPAs Moleski and Wallace observed doctor's orders received by the facility on 3/13/23 ordering R1 to take 5 milligrams of dementia medication once per day for two weeks, then increase to one tablet twice a day. MARs for R1 showed that R1 started the dementia medication on 3/14/23 with a dose of one tablet twice a day between 3/14/23 and 3/27/23. This facility is being cited per 22 CCR Section 87465(4). Appeal rights and a copy of this report was left with the administrator. An exit interview was conducted with the administrator.