Richmond Hill Assisted Living #3

The facility failed to accurately document medication administration on the electronic medication administration records (eMARs) for two residents. Specifically, multiple doses of clonazepam and lorazepam were documented as administered on the controlled substance count sheets (CSCS) but were missing from the eMARs.

The facility failed to accurately document medication administration on electronic medication administration records (eMARs) for 2 of 3 sampled residents. Specifically, for Resident #2, a dose of clonazepam administered on 06/10/25 was recorded on the controlled substance count sheet but was missing from the eMAR.

The facility failed to ensure at least one staff member on the premises at all times was certified in CPR and choking management. Specifically, an uncertified staff member worked alone during several shifts between May 13, 2025, and June 6, 2025, because the medication aide was frequently assigned to other facilities.

The facility failed to ensure accurate accounting and disbursement of personal funds for two residents. Specifically, the Administrator required a resident to pay room and board in cash rather than checks and failed to provide requested monthly billing statements or consistent receipts. This resulted in an unverified overdue balance and significant financial stress for the resident.

The facility failed to ensure necessary follow-up care and referrals for three residents following hospitalizations. Specifically, the facility did not document efforts to coordinate follow-up appointments with primary care providers, mental health providers, or neurology, and failed to facilitate necessary referrals for mental health and substance abuse treatment.

The facility failed to ensure necessary medical referrals and follow-up care for a resident. Specifically, the facility did not facilitate a required appointment with a pulmonologist and an ophthalmologist as ordered by the resident's primary care provider.

The facility failed to ensure necessary medical referrals and follow-up care for a resident. Specifically, the facility did not assist a resident in scheduling or attending required appointments with a pulmonologist and an ophthalmologist despite physician orders.

The facility failed to ensure at least one staff member on the premises at all times had completed CPR and choking management training within the last 24 months. Specifically, Staff B worked alone on February 14 and February 17, 2025, without possessing a valid CPR certification. This resulted in periods where no CPR-certified staff were present in the building.