complaint·November 14, 2025

On R1’s Rehabilitation discharge paperwork, Medication Ibuprofen was not listed as an active medication. LPA reviewed R1’s Medication Administration Record (MAR) dated from September 1, 2025 to November 14, 2025 and observed that R1 had an active order for Ibuprofen 200mg from 8/21/25 to 10/4/25. Facility MAR confirms R1 was given medication 8/21/25 to 9/25/25. Facility MAR notes that R1 did not receive Ibuprofen medication from 9/26/25- 10/3/25 due to R1 being out of facility. On 10/3/25, R1’s Service plan was updated and resident was assessed upon return from Rehabilitation facility. R1’s Updated Service plan states that R1 is actively on Medication Management, on med passes 4x a day and requires assistance with medications. LPA reviewed a Physician’s Medication Discontinuation order for Ibuprofen 200mg to be discontinued on 10/4/25. R1’s MAR notes from 10/4/25 to 10/31/25 Ibuprofen was discontinued and not administered to R1. Based on staff interviews, four of four staff stated that there has been no known medication errors regarding R1. Interviews with Four of four staff state that Medication Technicians, resident service director, resident service coordinator, memory care director and Caregiver staff that are medication trained are allowed to administer medications to residents. Staff interviews confirmed that discontinued orders need to be a physical hard copy from Physician or Nurse Practitioner and no verbal orders can be accepted. Based on records reviewed and interviews conducted, this agency has investigated the complaint alleging Staff do not ensure resident medications are given as prescribed. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and / or is without reasonable basis. An exit interview was conducted with Executive Director Nancy Rodriguez and a copy of this report was reviewed and provided at the time of this visit.