Complaint Investigation Report

Based on LPA’s record review of R1’s medications indicates that on 5/30/2025 R1 had a prescribed Olanzapine 5mg order to take two tablets daily at bedtime, dosage was decreased given urinary retention to Olanzapine 2.5mg to take 3 tablets by mouth daily at bedtime. On 7/8/25 there was a change of dosage to Olanzapine 5mg to take 1 tablet daily at bedtime. However, MARs provided for R1 including the months of June and July 2025, revealed that R1’s medication indicates: Olanzapine 5mg “take 1 tablet by mouth daily at bedtime”, which it was given to R1 not reflecting medication changes above prescribed. Based on LPA’s interviews conducted with the Licensee, information obtained supports that facility was aware of medication changes and did not perform adjustments to R1’s medication due to Licensee was confused regarding proper dosage to be provided to R1. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.