The Lodge at Riverton.

[R432-270-18(7)(a)-(f)] The licensee was out of compliance with R432-270-18(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, a review of the electronic medication administration records for 4 residents indicated that multiple medications were not administered according to the prescribing orders. This is a repeat non-compliance as noted on inspections dated June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, November 18, 2024, March 27, 2025, July 7, 2025, and September 11, 2025.

[R380-80-4(1)] The Licensee was out of compliance with R380-80-4(1) by not protecting each client from exploitation. Exploitation is defined in R380-80 as "the use of client's property, labor or resources without the client's consent or in manner that is contrary to the client's best interest, or for the gain of some person other than the client, including spending a client's funds for the benefit of another". During the inspection 1 resident was not protected from exploitation.

[R432-270-18(15)] The Licensee was out of compliance with R432-270-18(15) by not ensuring that medication error incident reports were completed if a medication error occurred or was identified. During the inspection, 3 residents did not receive their medications as prescribed and there was no medication error incident report completed for the errors. This is a repeat non-compliance as noted on June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, November 18, 2024, and March 27, 2025, and July 7, 2025. [R432-270-18(14)] The Licensee was out of compliance with R432-270-18(14) by not ensuring that the licensed health care professional was notified when medication errors occurred. During the inspection, medications were identified to not be administered as prescribed and the licensed healthcare professional was not notified. This is a repeat non-compliance as noted on June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, November 18, 2024, and March 27, 2025, and July 7, 2025. [R432-270-18(7)(a)-(f)] The licensee was out of compliance with R432-270-18(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, the electronic medical administration record for 3 residents was reviewed. This is a repeat non-compliance as noted on June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, November 18, 2024, March 27, 2025, and July 7, 2025. [R432-270-13(3)(a)-(d)] The Licensee was out of compliance with R432-270-13(3)(a)(c) and (d) by not ensuring that a resident’s service plan included a written description of the services to be provided, how the services were to be provided, the frequency of services, and who would provide the services. This is a repeat non-compliance as noted on July 7, 2025, August 13, 2025 and September 2, 2025.

[R432-270-8(8)(a)-(b)] The Licensee was out of compliance with R432-270- 8(8)(b)(ii) by not ensuring each employee’s orientation included an OL-approved core competency training. During the inspection, the licensor reviewed two employee’s files that did not have documentation of the employees completing core competency training. <br/><br/>Non compliance was previously cited on July 15,2024, July 7, 2025 and August 13, 2025 [R432-270-7(1)(a)-(n)] The Licensee was out of compliance with R432-270-7(1)(l) by not ensuring the administrator fulfilled all their duties. During the inspection, the licensor requested and reviewed incident reports from August 14, 2025 to the present. The incident reports did not include appropriate corrective actions. <br/><br/>Non compliance was previously cited on July 7, 2025 and August 13, 2025. [R432-270-24(1)] The licensee was out of compliance with R432-270-24(1), by not ensuring maintenance was conducted to ensure that facility spaces were safe, clean, in good repair and in compliance with Rule 432-6. During the inspection, the licensor completed an environmental tour of the facility and observed unsecured oxygen tanks in resident rooms, a missing shower handle, and soiled carpet.<br/><br/>Non compliance was previously cited on July 7 and August 13, 2025. [R432-270-13(3)(a)-(d)] The licensee was out of compliance with R432-270-13(3)(a-d) by not ensuring that a resident’s service plan included a written description of the services to be provided, how services are provided, frequency of services and who will provide the services. <br/><br/>Non compliance was previously cited on July 7 and August 13, 2025. [R432-270-12(3)(a)-(b)] The licensee was out of compliance with R432-270-12(3)(a) by not ensuring that the resident assessment accurately reflected the resident’s status when assessed. During the inspection the licensor reviewed one assessment that did not accurately reflect the resident’s status at the time of assessment.<br/><br/>Non compliance was previously cited on July 7 and August 13, 2025.

[R432-270-7(1)(a)-(n)] The Licensee was out of compliance with R432-270-7(1)(l) by not ensuring the administrator fulfilled all their duties. During the inspection, the licensor requested and reviewed incident reports from August 1, 2025 to the present. The incident reports did not include appropriate corrective actions. Non compliance was previously cited on July 7, 2025. [R432-270-15(2)(a)-(b)] The Licensee was out of compliance with R432-270-15(2) by not ensuring that each resident admitted to a secure unit had an admission agreement that indicated placement in the secure unit. During the inspection, 3 residents' admission paperwork was reviewed and they did not have a secure unit agreement or wander risk agreement in their files. Non compliance was previously cited on July 7, 2025. [R432-270-13(3)(a)-(d)] The Licensee was out of compliance with R432-270-13(3)(d) by not ensuring that service plans included a written description of who would provide the services to the resident. During the inspection, 3 resident's service plans were reviewed and they did not include who would provide the services to the resident. Non compliance was previously cited on July 7, 2025. [R432-270-10(8)(a)-(b)] The Licensee was out of compliance with R432-270-10(8)(a-b) by not ensuring that the prospective resident or the prospective resident's responsible person signed a written admission agreement before admission. During the inspection, 2 residents' files were reviewed and they did not have signed admission agreements. Non compliance was previously cited on July 7, 2025. [R432-270-9(2)(a)-(b)] The Licensee was out of compliance with 9(2)(a-b) by not ensuring that the administrator or designee gave each resident a written description of the resident's legal rights upon admission that included the following: a description of the manner of protecting personal funds and a statement that the resident may file a complaint with the state-long term care ombudsman and any other advocacy group concerning resident abuse, neglect, and misappropriation of resident property in the facility. During the inspection, the admission paperwork for 3 residents was reviewed that did not receive a copy of their written legal rights which included all of the aforementioned information. Non compliance was previously cited on July 7, 2025. [R432-270-27(6)] The Licensee was out of compliance with R432-270-27(6) by not ensuring pets kept at the facility had current vaccinations. During the inspection, the licensor requested the current vaccination records for 3 dogs and 1 cat kept at the facility. They were not provided. Non compliance was previously cited on July 7, 2025. [R432-270-25(8)(a)-(b)] The Licensee was out of compliance with R432-270-25(8)(a)(b)(i) and (ii) by not ensuring staff and residents received instruction and training in emergency procedures. During the inspection, the 2025 fire and disaster drills were requested and not provided. Non compliance was previously cited on July 7, 2025. [R432-270-24(1)] The Licensee was out of compliance with R43-270-24(1) by not ensuring that facility equipment and grounds were safe and in compliance with Rule R432-6. During the inspection, an environmental tour of the facility was conducted. Oxygen tanks were unsecured in 3 resident rooms. Non compliance was previously cited on July 7, 2025. [R432-270-8(8)(a)-(b)] The Licensee was out of compliance with R432-270-8(8)(b)(i)(ii)(iii)(iv)(v) and (vi) by not ensuring that employees completed orientation. During the inspection, a sample of employee files were reviewed and 2 employees were not oriented and trained on their job description; ethics, confidentiality, residents' rights; the fire and disaster plan; policies and procedures; the reporting responsibility for abuse, neglect and exploitation; and a department-approved core competency training. Non compliance was previously cited on July 7, 2025 and July 15,2024. [R432-270-9(3)] The Licensee was out of compliance with R432-270-9(3) by not ensuring that residents received all required paperwork upon admission. During the inspection, 3 resident's admission paperwork was reviewed. The resident or their responsible person were not notified, at the time of admission, in writing and in language and manner that the resident or the residents responsible person could understand, of the residents rights and rules governing resident conduct and responsibilities during the stay at the facility. Non compliance was previously cited on July 7, 2025.

[R432-270-9(7)(a)-(f)] The Licensee was out of compliance with R432-270-9(7)(a)-(f) by not ensuring that employees completed orientation. During the inspection, a sample of employee files were reviewed and 6 employees were not oriented and trained on their job description; ethics, confidentiality, and residents' rights; the fire and disaster plan; policies and procedures; the reporting responsibility for abuse, neglect and exploitation; and a department-approved core competency training. This is a repeat non-compliance as noted on July 15, 2024. [R432-270-21(1)] The Licensee was out of compliance with R432-270-21(1) by not ensuring records were easily accessible to staff and the department. During the inspection, the licensor requested a discharged resident's file and the 2025 fire drill documentation. The documentation was not provided. This is a repeat non-compliance as noted on 6/4/2024, 6/25/2024, 7/29/2024, 8/20/2024, and 9/11/2024 [R432-270-19(15)] The Licensee was out of compliance with R432-270-19(15) by not ensuring that medication error incident reports were completed if a medication error occurred or was identified. During the inspection, 2 residents did not receive their medications as prescribed and there was no medication error incident report completed for the errors. This is a repeat non-compliance as noted on June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, November 18, 2024, and March 27, 2025. [R432-270-19(14)] The Licensee was out of compliance with R432-270-19(14) by not ensuring that the licensed health care professional was notified when medication errors occured. During the inspection, there was no documentation that the licensed health care professional was notified for 23 medication errors. This is a repeat non-compliance as noted on June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, November 18, 2024, and March 27, 2025. [R432-270-19(7)(a)-(f)] The Licensee was out of compliance with R432-270-19(7)(b)(d) by not ensuring that facility staff only adminstered medications after delegation by a licensed health care professional under the scope of their practice and by not ensuring medications were administered according to the prescribing order. During the inspection, 4 medication administration technicians files were reviewed and they were not delegated by the facility's current health care professional and medications were not administered according to the prescribing order for 2 residents. This is a repeat non-compliance as noted on June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, November 18, 2024, and March 27, 2025. [R432-270-11(10)(a)-(c)] The Licensee was out of compliance with R432-270-11(10)(c)(i) by not developing emergency evacuation plans for hospice patient residents, who needed help with evacuation. During the inspection, 1 resident was identified to be receiving hospice services and could not evacuate without significant assistance. Their file was reviewed and the licensee did not have an emergency evacuation plan for this resident.

[R432-270-19(14)] The Licensee was out of compliance with R432-270-19(14) by not ensuring the licensed health care professional was notified when medication errors occurred. During the inspection, the licensor identified 1 resident who had not received a diuretic medication for 10 days and was subsequently admitted to the hospital for 3 days for fluid retention and overload. The Licensee did not provide evidence that the licensed health care professional was notified when the medication errors occurred.<br/><br/>This noncompliance was previously cited during inspections dated June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, and November 18, 2024. [R432-270-19(7)(a)-(f)] The Licensee was out of compliance with R432-270-19-7(d) by not ensuring medications were administered according to the prescribing order. During the inspection, 1 resident was identified as not receiving diuretic medication for 10 days and was subsequently admitted to the hospital for 3 days for fluid retention and overload.<br/><br/>This noncompliance was previously cited during inspections dated June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, and November 18, 2024. [R380-600-7(16)(a)-(d)] The Licensee was out of compliance with R380-600-7(16)(a) by not reporting a critical incident to the office within one business day. During the inspection, the licensor identified that 1 resident was admitted to the hospital due to difficulty breathing, and a critical incident report was not submitted to the office. [R432-270-19(15)] The Licensee was out of compliance with R432-270-19(15) by not ensuring medication error incident reports were completed if a medication error occurred or was identified. During the inspection, 1 resident was identified as not receiving medication for approximately 10 days, which subsequently led to their hospitalization. The Licensee did not provide evidence that medication error incident reports were completed for the days of unavailable medication.<br/><br/>This noncompliance was previously during inspections dated June 4, 2024, June 25, 2024, July 29, 2024, August 20, 2024, September 11, 2024, and November 18, 2024.

[R432-270-19(7)(a)-(f)] The provider was out of compliance with this rule by not ensuring medications were administered according to the prescribing order. During the inspection, 2 residents did not receive their medications as prescribed. <br/><br/>This noncompliance was previously cited on 6/4/2024, 6/25/2024, 7/29/2024, 08/20/2024 and 9/11/2024 [R432-270-19(15)] The provider was out of compliance with this rule by not ensuring that medication error incident reports were completed when medication errors occurred. During the inspection, medications were identified to not be administered as prescribed and medication error incident reports were not completed.<br/><br/>This noncompliance was previously cited on 6/4/2024, 6/25/2024, 7/29/2024 and 08/20/2024, and 09/11/2024. [R432-270-19(14)] The provider was out of compliance with this rule by not ensuring that the licensed healthcare professional was notified when medication errors occurred. During the inspection, medications were identified to not be administered as prescribed and the licensed healthcare professional was not notified.<br/><br/>This noncompliance was previously cited on 6/4/2024, 6/25/2024, 7/29/2024 and 08/20/2024, and 09/11/2024. [R432-1-4(1)(a)-(b)] The provider was out of compliance with this rule by not ensuring that all direct care staff were wearing identification badges. During the inspection, two direct care staff was observed without an identification badge.<br/><br/>This is a repeat noncompliance from 7/15/2024, 7/29/2024 and 08/20/2024, and 09/11/2024.

[R432-270-19(7)(a)-(f)] The provider was out of compliance with this rule by not ensuring that medications were administered according to the prescribed order. During the inspection, 6 residents did not receive their medications as prescribed.<br/><br/>This noncompliance was previously cited on 6/4/2024, 6/25/2024, 7/29/2024 and 08/20/2024. [R432-270-19(15)] The provider was out of compliance with this rule by not ensuring that medication error incident reports were completed when medication errors occurred. During the inspection, medications were identified to not be administered as prescribed and medication error incident reports were not completed.<br/><br/>This noncompliance was previously cited on 6/4/2024, 6/25/2024, 7/29/2024 and 08/20/2024. [R432-270-19(14)] The provider was out of compliance with this rule by not ensuring that the licensed healthcare professional was notified when medication errors occurred. During the inspection, medications were identified to not be administered as prescribed and the licensed healthcare professional was not notified.<br/><br/>This noncompliance was previously cited on 6/4/2024, 6/25/2024, 7/29/2024 and 08/20/2024. [R432-1-4(1)(a)-(b)] The provider was out of compliance with this rule by not ensuring that all direct care staff were wearing identification badges. During the inspection, two direct care staff was observed without an identification badge.<br/><br/>This is a repeat noncompliance from 7/15/2024, 7/29/2024 and 08/20/2024. [R432-270-21(1)] The provider was out of compliance with this rule by not ensuring that resident records were accurate. During the inspection, 3 resident medication administration records were not accurate.<br/><br/>This noncompliance was previously cited on 6/4/2024, 6/25/2024, 7/29/2024 and 08/20/2024.

[R432-270-21(1)] The provider was out of compliance with this rule by not ensuring that resident records were accurate. During the inspection, 1 resident medication administration record was not accurate. This noncompliance was previously cited on 6/4/2024, 6/25/2024 and 7/29/2024. [R432-270-19(15)] The provider was out of compliance with this rule by not ensuring that medication error incident reports were completed when medication errors occurred. During the inspection, medications were identified to not be administered as prescribed and medication error incident reports were not completed. This noncompliance was previously cited on 6/4/2024, 6/25/2024 and 7/29/2024. [R432-270-19(14)] The provider was out of compliance with this rule by not ensuring that the licensed healthcare professional was notified when medication errors occurred. During the inspection, medications were identified to not be administered as prescribed and the licensed healthcare professional was not notified. This noncompliance was previously cited on 6/4/2024, 6/25/2024 and 7/29/2024. [R432-270-19(7)(a)-(f)] The provider was out of compliance with this rule by not ensuring that medications were administered according to the prescribed order. During the inspection, 4 residents did not receive their medications as prescribed. This noncompliance was previously cited on 6/4/2024, 6/25/2024 and 7/29/2024. [R432-1-4(1)(a)-(b)] The provider was out of compliance with this rule by not ensuring that direct care staff were wearing identification badges. During the inspection, 4 direct care staff were observed without name badges. This is a repeat noncompliance from 7/15/2024 and 7/29/2024.

[R432-270-8(1)(a)-(p)] The provider was out of compliance with this rule by not ensuring that a thorough investigation was completed when there was a reason to believe a resident had been subjected to abuse or exploitation. During the 6/4/2024 inspection, a resident was identified to have had a card of controlled substances go missing and a thorough investigation was not completed. That investigation along with any other investigations completed since the prior inspection was requested and could not be provided.<br/><br/>This noncompliance was previously cited on 6/4/2024.

[R432-270-8(1)(a)-(p)] The provider was out of compliance with this rule by not ensuring that a thorough investigation was completed when there was a reason to believe a resident had been subjected to abuse or exploitation. During the inspection, a resident was identified to have had a card of controlled substances go missing and a thorough investigation was not completed.