Meliora Health Assisted Living LLC

Based on record review, documentation review, and interview, the manager failed to ensure that a resident’s medical record contained documentation of medication administered to the resident that includeed the date and time of administration; the name, strength, dosage, and route of administration; the name and signature of the individual administering the medication; and and unexpected reaction the resident has to the medication. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed no documentation of a September 2025 medication administration record (MAR). 2. Documentation review revealed a policy titled Dispensing & Tracking of Medication that stated, "A Manager shall ensure that a resident's MAR is generated and documented to reflect residents' medication administration or treatment orders from the medical practitioners and in the service plan, including controlled substances." 3. In an interview, E2 reported R1 received medication administration. E2 reported that the September 2025 MAR was at E2's personal home. 4. In an exit interview, the findings were discussed with E2 and no additional information was provided.