Richmond Hill Assisted Living 1

The facility failed to ensure the availability of at least one telephone that does not require electricity or cellular service to operate. Residents were unable to make calls because the hard-wired telephones in the dining room were non-functional for several months.

The facility failed to ensure the implementation of an activities program that promoted active involvement and engagement of residents. Observations revealed that the posted activity calendar was outdated from November 2025, and residents reported that listed activities were rarely done.

The facility failed to maintain at least one telephone that does not require electricity or cellular service to operate. Multiple residents and staff reported that the facility telephones had been non-functional for several months, forcing residents to rely on staff personal cell phones or walk to other buildings to make calls.

The facility failed to maintain at least one telephone that operates without the need for electricity or cellular service. As a result, multiple residents were unable to contact family or guardians, with some reporting the telephone had been non-functional for several months.

The facility failed to ensure at least one staff member on the premises at all times was certified in CPR and choking management. Specifically, Staff A worked alone for five twelve-hour shifts between 5/10/2025 and 6/11/2025 without valid CPR certification.

The facility failed to ensure that designated managers (Staff A and B) earned the required 12 hours of annual continuing education credits related to management or resident care. Specifically, Staff A's personnel record lacked documentation of a hire date, job title, and required continuing education credits.

The facility lacked a standardized system for making resident records readily available for review by staff and agencies.

The facility failed to maintain complete personnel records for SICs and clinical leaders, specifically lacking high school diplomas, certifications, and letters of reference regarding supervisory experience.

The facility failed to ensure secure and accessible resident rooms, necessitating the installation of new locks and keys and the establishment of a master key system.

The facility lacked a consistent, documented rounding process to ensure residents receive necessary assistance and incontinence care every two hours.

The facility failed to adequately supervise residents deemed unsafe to smoke independently, requiring new protocols for supervision, documentation, and potential discharge.

The facility failed to provide adequate dietary information and portion control, requiring the implementation of weekly menus, serving guides, and daily dining room postings.

The facility failed to maintain an accessible and updated list of resident diets and food allergies in the kitchen area.

The facility lacked a structured activity program and documentation system, requiring the development of a monthly calendar with specific times and electronic tracking of participation.

The facility failed to perform regular inspections of resident beds to ensure they are in good repair and safe for use.

The facility failed to ensure timely processing and transcription of medication orders into the EMAR upon receipt from pharmacies.

The facility failed to perform daily audits of controlled substance logs against the EMAR to ensure accurate documentation and discrepancy reporting.

The facility failed to provide an accurate accounting of resident personal funds used for medication co-payments. While the Resident Trust Transaction Log showed monthly deductions for pharmacy bills, the pharmacy confirmed no payments had been received since June 2023, leaving Resident #1 with an unpaid balance of $419.39.

The facility failed to provide an accurate accounting of resident personal funds for one resident. While the facility's logs showed monthly payments made toward pharmacy co-payments, pharmacy records showed no payments received since June 2023, leaving a significant unpaid balance.