Complaint·August 26, 2025

Regarding the allegation, staff mismanages resident's medications, according to the reporting party, it was observed that staff have been incorrectly documenting R1’s Olanzapine dosage. According to the medication log, the facility has documented that R1’s Olanzapine dosage is 40mg daily at bedtime, however the correct dosage is only 2.5mg at bedtime. During the investigation, LPA reviewed R1’s file including but not limited to; physician's orders for medication, medication administration record (MAR), and R1's medication bottles. According to staff interviewed, R1 is receiving the correct dosage of Olanzapine as prescribed by the physician, however the new electronic MAR system listed the Olanzapine medication dosage incorrectly. LPA reviewed R1’s medication bottle and observed it to show that R1 is supposed to receive 2.5mg of Olanzapine daily at bedtime. Medication count was conducted and all medications are accounted for. Facility MAR was reviewed, and the facility corrected the dosage error on their electronic system. Although the MAR system listed the dosage for R1’s Olanzapine incorrectly, the facility is administering R1’s medication as prescribed by the physician. Based on interviews conducted, records reviewed, observations, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with Administrator, Paula Madrigal and a copy is provided.