River Rose Senior Care LLC

Based on documentation review and interview, the assisted living center failed to maintain a copy of the document provided to an emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of an emergency. Findings include: 1. A review of R1’s medical record revealed a gap in the dates of services provided to R1. In an interview, E1 reported R1 threw a table and was sent to the hospital for evaluation on January 8, 2026. E1 further reported R1 was sent out to the hospital again on February 13, 2026. 2. During the inspection, the compliance officer requested to review the document provided to the emergency responders. 3. E1 reported E1 did not have a copy of the documentation required. E1 provided a form that was not completely filled out and reported the medication administration record was accidentally sent with R1 to the hospital on February 13, 2026. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the manager failed to provide written notification to the Department of a resident’s elopement, within 24 hours of the elopement being discovered. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for the other residents residing in the assisted living facility. Findings Include: 1. The Compliance Officer reviewed an incident report dated February 5, 2026, which indicated R1 eloped on February 5, 2026. 2. No evidence was provided that the Department was notified of the elopement. 3. In an interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, the manager failed to ensure a residency agreement was signed and dated by the manager before or at the time of an individual's acceptance by the assisted living facility, for one of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a residency agreement. However, the residency agreement did not include the manager’s signature and date signed. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan that, when initially developed and when updated, was signed and dated by the resident or resident’s representative, the manager, and the nurse or medical practitioner who reviewed the service plan, for one of two resident records reviewed. Findings include: 1. A review of R1’s medical records revealed an initial service plan dated January 8, 2026, that included medication administration. The service plan had a signature of the resident’s representative; however, it did not include the date signed. Further review revealed it did not include the signature of the manager or the nurse who reviewed the service plan. 2. In an exit interview, the findings were reviewed with E1 and no further information was provided.

Based on record review and interview, the manager failed to ensure that a resident’s medical record contained documentation of medication administered to the resident that included the date and time of administration; the name, strength, dosage, and route of administration; and the name and signature of the individual administering the medication for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's medical record revealed an unsigned service plan, dated January 8, 2026, which included medication administration. 2. A review of R1’s medical record revealed signed medication orders dated January 22, 2026, which included daily administration orders for amlodipine, aspirin, atorvastatin, carvedilol, losartan, and Quetiapine. 3. Further review of R1’s medical record revealed no evidence of a medication administration record (MAR) or documentation of the administration of R1’s medication, which included the date and time of administration; the name, strength, dosage, and route of administration; and the name and signature of the individual administering the medication. 4. In an exit interview, the findings were reviewed with E1. E1 reported the MAR was accidentally sent with R1 to the hospital, on February 13, 2026.

Based on record review and interview, when a resident had an emergency that resulted in the resident needing emergency services, the manager failed to ensure a caregiver or an assistant caregiver documented the incident as required. Finding include: 1. A review of R1’s medical record revealed a gap in the dates of services provided to R1. In an interview, E1 reported R1 threw a table and was sent to the hospital for evaluation on January 8, 2026. E1 further reported R1 was sent out to the hospital again on February 13, 2026, for throwing a stool at E2. 2. The compliance officer requested to review an incident report regarding the incidents that occurred on January 8, 2026 and on February 13, 2026. E1 reported incident reports were unavailable for review, for the two incidents requested. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.