Inspection Reports for
Recover-Care Richmond LLC
340 E. SOUTH STREET, RICHMOND, KS, 66080-4021
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
25.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
328% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
80% occupied
Based on a November 2017 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Nov 9, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including residents' rights notices, grievance resolution, telephone access privacy, safe transfer/discharge procedures, housekeeping and maintenance issues, comprehensive assessments, assessment accuracy, pressure ulcer treatment, infection control, and environmental safety.
Deficiencies (10)
F 156 D Notices of Rights, Rules, Services, Charges were deficient as some residents did not receive required Medicare A discharge notices timely.
F 166 D Right to Prompt Efforts to Resolve Grievances was deficient due to delayed grievance resolution and missing items like a razor.
F 174 E Right to Telephone Access with Privacy was deficient; facility purchased a cordless phone and will install a dedicated line for resident use.
F 204 D Preparation for Safe/Orderly Transfer/Discharge was deficient due to incomplete discharge documentation and notification.
F 253 E Housekeeping & Maintenance Services were deficient with multiple repair and cleanliness issues throughout the facility.
F 272 E Comprehensive Assessments were deficient; some residents lacked timely annual assessments with CAAS completion.
F 278 D Assessment Accuracy was deficient; diagnosis coding errors were identified and education planned.
F 314 D Treatment/services to prevent/heal pressure ulcers were deficient; treatment orders were not consistently followed.
F 441 F Infection Control was deficient; infection control rounding and antibiotic tracking were initiated.
F 465 E Safe, Functional, Sanitary, Comfortable Environment was deficient; maintenance and housekeeping issues were corrected.
Report Facts
Deficiencies cited: 10
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 10
Date: Nov 9, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint numbers.
Complaint Details
The inspection included complaint investigations #122882, #105076, #108319, and #104285.
Findings
The facility was found deficient in multiple areas including failure to timely notify residents of Medicare A benefit termination, failure to resolve resident grievances, lack of private telephone access, insufficient discharge preparation, poor housekeeping and maintenance, incomplete resident assessments, inaccurate MDS assessments, inadequate pressure ulcer treatment, and failure to maintain an effective infection control program.
Deficiencies (10)
F156: The facility failed to notify residents or responsible parties timely of Medicare A benefit termination and provide proper appeal information for 3 residents.
F166: The facility failed to promptly resolve a grievance related to a missing razor for resident #35.
F174: The facility failed to provide residents reasonable access to a telephone to make private calls.
F204: The facility failed to provide and document sufficient preparation and orientation to resident #80 prior to discharge to ensure a safe and orderly discharge.
F253: The facility failed to maintain a sanitary, orderly, and comfortable interior in 10 resident rooms and 2 hallways, including damaged doors, walls, and unclean areas.
F272: The facility failed to complete further analysis of triggered care area assessments for 5 residents to address underlying causes and risk factors.
F278: The facility failed to complete an accurate comprehensive assessment for resident #65 regarding volume depletion and GI bleed that had resolved.
F314: The facility failed to provide necessary treatment to promote healing of a pressure ulcer for resident #60 as ordered by the physician.
F441: The facility failed to maintain an infection control program by not trending infections and pathogens and failed to keep resident items off the floor to prevent infection.
F465: The facility failed to provide maintenance services necessary to maintain an orderly environment in 1 staff bathroom and 2 supply rooms.
Report Facts
Residents with urinary tract infections: 1
Residents with urinary tract infections: 5
Residents with urinary tract infections: 3
Residents with urinary tract infections: 1
Residents with urinary tract infections: 4
Pressure ulcer wound size: 15
Pressure ulcer wound size: 10
Pressure ulcer wound size: 9
Pressure ulcer wound size: 7
Resident census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Verified issues with Medicare A benefit notices, discharge planning, and environmental concerns | |
| Social service staff F | Social Service Designee | Confirmed liability letters lacked appeal contact info and discharge planning issues |
| Licensed nursing staff J | Performed wound care but failed to apply skin prep as ordered | |
| Administrative nursing staff C | Verified lack of analysis in CAAs and infection control deficiencies | |
| Licensed nursing staff E | Commented on incomplete CAAs and MDS assessments |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 18, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies listed on the CMS-2567 were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 18, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 03/18/2016.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 18, 2016
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 03/18/2016.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Mar 9, 2016
Visit Reason
This document is a Plan of Correction submitted by Richmond Healthcare and Rehab in response to a prior deficiency report, outlining corrective actions to address identified deficiencies.
Findings
The plan details corrective actions including staff re-education, monitoring logs, repairs, and audits to address issues such as notification failures, resident fund management, environmental cleanliness, pressure ulcer care, vital sign monitoring, dietary service deficiencies, call light functionality, and medical record management.
Deficiencies (11)
F157-D: Resident #52 no longer resides at the center; nursing staff re-educated on incident reporting and notification procedures.
F160-D: Business Office Manager issued refunds to affected residents and re-educated on fund return policies.
F253-E: Housekeeping and maintenance addressed cleanliness and repairs; monitoring logs established for ongoing maintenance.
F278-D: Resident #52 no longer resides at the center; reassessments and audits conducted for pressure ulcer coding and care.
F314-D: Director of Nursing reviewed pressure ulcer treatment; staff re-educated on skin inspections and documentation.
F329-D: Re-education on vital sign policy and pain management; MAR/TAR audit tool initiated for monitoring.
F363-E: Dietary staff educated on ensuring all menu items are served; monitoring of meals implemented.
F371-F: Kitchen appliances cleaned; undated supplements discarded; cleaning schedules updated and staff educated.
F463-E: Maintenance replaced call lights; monitoring and staff re-education planned for call light functionality.
F514-E: Medical records reviewed and reorganized; re-education provided to Medical Record designee; audits scheduled.
S600-F: Dietary Manager to enroll in certification program; oversight by Registered Dietician and Administrator monitoring progress.
Report Facts
Affected residents refunded: 3
Monitoring periods: 4
Monitoring periods: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Modified the Plan of Correction |
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 4
Date: Feb 24, 2016
Visit Reason
The inspection was a Health Resurvey and complaint investigations #83533 and #95619 to assess compliance with dietary services regulations.
Complaint Details
The visit included complaint investigations #83533 and #95619 as part of the Health Resurvey.
Findings
The facility failed to retain a full-time certified dietary manager and maintain a clean and sanitary dietary department. Observations revealed unclean kitchen equipment, improperly cleaned food preparation areas, and staff lacking knowledge of disinfectant wet times.
Deficiencies (4)
28-39-158(a) Dietary services. The facility failed to retain a full-time certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department. Observations found food spillage in the oven, undated liquid supplements, and spills in the refrigerator.
Sanitation tour revealed damaged non-stick skillets and grill with heavy soiled build-up, dirty sheet pans, dusty ceiling vents, and food crumbs in a hot food cart.
Direct care staff performed nail care on a dining room table without cleaning the table before residents used it for meals, indicating inadequate sanitation practices.
Staff lacked training and knowledge on required disinfectant wet times for cleaning tables, compromising sanitation standards.
Report Facts
Resident census: 48
Sanitizer wet time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff I | Dietary department manager | Reported as manager but not certified and failed to complete certification class |
| Housekeeping staff R | Reported disinfectant wet time for Virex 112-56 | |
| Administrative nursing staff A | Reported unawareness of staff knowledge regarding disinfectant wet time | |
| Administrative staff N | Reported dietary staff I served as manager but was not certified |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 24, 2016
Visit Reason
The visit was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 24, 2016
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The survey found 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 5, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited for deficiencies at the 'F' severity level related to Life Safety Code compliance. These deficiencies posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Feb 5, 2016
Provider agreement termination date: May 5, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process regarding cited deficiencies. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Nov 5, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended due to failure to achieve substantial compliance.
Deficiencies (1)
The facility was cited with deficiencies at an 'F' level under the Life Safety Code survey, indicating issues with compliance but no immediate jeopardy to residents.
Report Facts
Effective date for denial of payments: Feb 5, 2016
Provider agreement termination date: May 5, 2016
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution requests related to the survey deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 19, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
The Plan of Correction states that the facility is addressing deficiencies related to dietary management by enrolling the Dietary Manager in a Certified Dietary Manager program to achieve certification.
Deficiencies (1)
S600 SS=C: Facility administrator located a Certified Dietary Manager program at the University of North Dakota. The Dietary Manager will enroll in the program to complete the 270-hour certification course under the guidance of a Registered Dietician.
Report Facts
Program hours: 270
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 12, 2015
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at Richmond Healthcare & Rehab Center.
Findings
The report documents that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 2015-01-19.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited was corrected by 2015-01-19.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 12, 2015
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the deficiency identified under regulation 28-39-158(a) with prefix code S0600 was corrected as of 2015-01-19.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited under prefix S0600 was corrected on 2015-01-19.
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 1
Date: Jan 12, 2015
Visit Reason
The visit was a non-compliant revisit to verify correction of previously cited deficiencies related to dietary services.
Findings
The facility failed to retain the services of a certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department for food storage, preparation, and service to residents.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to retain a certified dietary manager to perform managerial duties overseeing dietary staff and maintaining a clean and sanitary dietary department for food storage, preparation, and service.
Report Facts
Census: 42
Inspection Report
Follow-Up
Deficiencies: 17
Date: Jan 12, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report documents that all previously cited deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of 12/14/2014.
Deficiencies (17)
Regulation 483.10(i)(1) deficiency was corrected on 12/14/2014.
Regulation 483.10(k),(l) deficiency was corrected on 12/14/2014.
Regulation 483.15(a) deficiency was corrected on 12/14/2014.
Regulation 483.15(c)(6) deficiency was corrected on 12/14/2014.
Regulation 483.15(h)(2) deficiency was corrected on 12/14/2014.
Regulation 483.20(b)(1) deficiency was corrected on 12/14/2014.
Regulation 483.20(d)(3), 483.10(k)(2) deficiency was corrected on 12/14/2014.
Regulation 483.25 deficiency was corrected on 12/14/2014.
Regulation 483.25(a)(3) deficiency was corrected on 12/14/2014.
Regulation 483.25(d) deficiency was corrected on 12/14/2014.
Regulation 483.25(h) deficiency was corrected on 12/14/2014.
Regulation 483.25(k) deficiency was corrected on 12/14/2014.
Regulation 483.25(l) deficiency was corrected on 12/14/2014.
Regulation 483.35(i) deficiency was corrected on 12/14/2014.
Regulation 483.55(b) deficiency was corrected on 12/14/2014.
Regulation 483.60(c) deficiency was corrected on 12/14/2014.
Regulation 483.65 deficiency was corrected on 12/14/2014.
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Dec 14, 2014
Visit Reason
This document is a Plan of Correction submitted by Richmond Healthcare and Rehabilitation Center addressing deficiencies identified in a prior inspection.
Findings
The Plan of Correction details corrective actions taken or planned for multiple deficiencies including mail delivery, personal property loss, resident care preferences, facility maintenance, resident assessments, care planning, hospice coordination, grooming and oral care, bowel and bladder management, incident and accident management, prosthetic care, medication management, dietary services, dental referrals, and laundry services.
Deficiencies (18)
F170 E: No possible correction for past untimely delivery of mail. Assigned staff will deliver mail on weekends and staff educated on mail delivery.
F174 D: Search conducted for missing resident needlework. Staff educated on theft and loss of personal property and grievance procedures.
F241 D: Sign removed from resident room. Staff educated on addressing residents by preferred names and care plans updated accordingly.
F244 E: No immediate correction for resident council grievance follow-up. Staff educated on grievance response process and monitoring established.
F253 E: Maintenance issues corrected including hair on sink, broken floor tiles, laminate repairs, and cleaning. Staff educated on housekeeping standards and monitoring implemented.
F272 D: Residents reassessed for urinary incontinence and ADLs. Staff educated on Resident Assessment Instrument and monitoring planned.
F280 D: Care plans updated for residents. Staff educated on care planning policy and monitoring of care plan updates established.
F309 D: No correction possible for deceased resident. Staff educated on hospice coordination and monitoring of hospice care records planned.
F312 D: Residents reassessed and provided grooming care. Staff educated on grooming and oral care policies with monitoring of compliance.
F315 D: Resident reassessed. Staff educated on bowel and bladder management policies with monitoring of compliance.
F323 D: Care plans updated and staff educated on incident, accident, elopement, and care planning policies. Monitoring of care plans and incident logs established.
F328 D: Prosthetic assessed and resident deemed inappropriate for use. Weekly skin assessments and staff education on prosthetic-related skin integrity implemented.
F329 D: Residents reassessed. Staff educated on standing orders and ADL documentation with monitoring of ADL books.
F371 F: Dietary staff corrected hygiene and cleaning issues. Temperature logs and cleaning schedules implemented. Staff education planned and monitoring established.
F412 D: Resident reassessed for dental status. Staff educated on dental referrals and social service updates. Monitoring of dental services provided.
F428 D: Residents reassessed for medication management. Pharmacy provides drug review lists and staff educated on implementation. Monitoring of medication processes planned.
F441 F: Textiles moved off floor. Staff educated on linen handling and personal protective equipment. Monitoring of laundry compliance established.
S600 F: Dietary hygiene and food temperature issues corrected. Staff education and cleaning schedules implemented. Dietary Manager enrollment in certification program planned with monitoring.
Report Facts
Monitoring duration: 8
Monitoring duration: 12
Monitoring duration: 4
Monitoring duration: 12
Monitoring frequency: 2
Monitoring duration: 3
Inspection Report
Enforcement
Deficiencies: 0
Date: Nov 14, 2014
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an "F" level. As a result, enforcement remedies including denial of payment for new Medicare admissions were imposed effective February 14, 2015.
Report Facts
Enforcement effective date: Feb 14, 2015
Compliance deadline: May 14, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Enforcement
Deficiencies: 0
Date: Nov 14, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at an 'F' level, resulting in enforcement remedies including denial of payment for new Medicare admissions effective February 14, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of payment effective date: Feb 14, 2015
Substantial compliance deadline: May 14, 2015
Civil Money Penalty threshold: 5000
IDR submission deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 17
Date: Nov 14, 2014
Visit Reason
Health Resurvey and complaint investigations #79277 and #79675 were conducted to assess compliance with resident rights, dignity, care, and safety.
Complaint Details
The inspection was conducted as a result of complaint investigations #79277 and #79675.
Findings
The facility was found deficient in multiple areas including residents' rights to privacy and mail delivery, dignity and respect, grievance follow-up, housekeeping and maintenance, comprehensive assessments, care planning, provision of care, infection control, dental services, medication regimen review, and fall prevention.
Deficiencies (17)
F170: Facility failed to ensure residents promptly received mail, especially on weekends, violating privacy rights.
F174: Facility failed to ensure one resident retained personal property and failed to investigate missing items.
F241: Facility failed to promote dignity and respect by posting personal care instructions in resident's room and using terms of endearment instead of residents' names.
F244: Facility failed to act upon grievances and recommendations voiced during resident council meetings.
F253: Facility failed to maintain sanitary and comfortable environment; multiple maintenance and housekeeping deficiencies noted throughout facility.
F272: Facility failed to complete comprehensive assessments for residents, including urinary incontinence and ADL functional rehabilitation.
F280: Facility failed to review and revise care plans for residents after accidents and falls, missing interventions to prevent further falls.
F309: Facility failed to coordinate hospice care services to assure highest practicable well-being; care plan lacked hospice visit details and equipment listing.
F312: Facility failed to provide necessary services to maintain good grooming and oral hygiene for residents, including nail care and oral care.
F315: Facility failed to provide appropriate treatment and services to restore bladder function and prevent urinary tract infections for a resident with urinary incontinence.
F323: Facility failed to provide adequate supervision and assistive devices to prevent accidents and falls; failed to monitor alarms and implement interventions after falls; failed to monitor and secure exit doors during fire drill leading to resident elopement.
F328: Facility failed to provide proper treatment and care for resident's prosthesis; prosthesis did not fit properly and facility failed to contact prosthetic company for adjustments.
F329: Facility failed to monitor bowel elimination and follow physician's standing orders for laxative administration for residents with constipation.
F371: Facility failed to maintain a clean and sanitary dietary department; multiple sanitation and food safety violations observed including uncovered hair, undated food, dirty equipment, and improper food handling.
F412: Facility failed to ensure dental services were available and offered to a resident with dentures needing adjustment; resident was not offered dental program available to Medicaid residents.
F428: Facility failed to conduct monthly drug regimen review for a resident and failed to follow up on pharmacist's recommendation for medication dose reduction.
F441: Facility failed to maintain sanitary environment and prevent infection during laundry handling; soiled laundry was sorted on floor, laundry carts uncovered, and PPE use was inadequate.
Report Facts
Resident census: 38
Deficiency counts: 16
Resident bowel movement gap: 5
Resident bowel movement gap: 4
Resident toileting opportunity gap: 230
Resident toileting opportunity gap: 117
Resident toileting opportunity gap: 182
Resident falls: 4
Resident falls: 2
Resident falls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff BB | Administrative Staff | Named in mail delivery deficiency |
| Staff CC | Licensed Staff | Named in mail delivery and dignity findings |
| Staff F | Social Service Staff | Named in personal property grievance follow-up deficiency |
| Staff P | Licensed Nursing Staff | Named in dignity and fall prevention findings |
| Staff V | Direct Care Staff | Named in dignity and toileting care findings |
| Staff W | Direct Care Staff | Named in mail delivery, toileting, and bowel care findings |
| Staff Y | Licensed Staff | Named in toileting, prosthesis, and bowel care findings |
| Staff E | Activity Staff | Named in grievance and nail care findings |
| Staff L | Direct Care Staff | Named in dignity, toileting, and fall prevention findings |
| Staff Q | Direct Care Staff | Named in toileting care findings |
| Staff R | Direct Care Staff | Named in toileting care and fall prevention findings |
| Staff S | Direct Care Staff | Named in toileting care and fall prevention findings |
| Staff T | Direct Care Staff | Named in toileting care findings |
| Staff U | Direct Care Staff | Named in toileting care and bowel care findings |
| Staff K | Direct Care Staff | Named in fall prevention findings |
| Staff N | Licensed Nursing Staff | Named in elopement and fall prevention findings |
| Staff CC | Licensed Nursing Staff | Named in dental services findings |
| Staff F | Social Service Staff | Named in dental services findings |
| Staff AA | Consultant Pharmacy Staff | Named in drug regimen review findings |
| Staff D | Dietary Staff | Named in dietary sanitation findings |
| Staff P | Licensed Nursing Staff | Named in dietary sanitation findings |
| Staff EE | Dietary Staff | Named in dietary sanitation findings |
| Staff II | Laundry Staff | Named in laundry sanitation findings |
| Staff M | Contract Direct Care Staff | Named in hospice care findings |
| Staff O | Hospice Licensed Nursing Staff | Named in hospice care findings |
| Staff B | Licensed Administrative Staff | Named in multiple findings including fall prevention and hospice care |
| Staff I | Licensed Administrative Staff | Named in toileting and prosthesis care findings |
| Staff J | Direct Care Staff | Named in prosthesis care findings |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 3, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies at Richmond Healthcare & Rehab Center.
Findings
The revisit confirmed that the previously reported deficiencies under regulations 483.20(k)(3)(i) and 483.25(d) were corrected as of 08/06/2014.
Deficiencies (2)
Regulation 483.20(k)(3)(i): Previously cited deficiency was corrected by 08/06/2014.
Regulation 483.25(d): Previously cited deficiency was corrected by 08/06/2014.
Report Facts
Correction completion date: Deficiencies under regulations 483.20(k)(3)(i) and 483.25(d) corrected on 08/06/2014
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 3, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.20(k)(3)(i) and 483.25(d) were corrected by 08/06/2014. No uncorrected deficiencies remain as of the revisit date.
Deficiencies (2)
Regulation 483.20(k)(3)(i) deficiency was corrected by 08/06/2014.
Regulation 483.25(d) deficiency was corrected by 08/06/2014.
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 31, 2014
Visit Reason
This document is a Plan of Correction submitted by Richmond Healthcare in response to deficiencies cited during a complaint survey.
Findings
The facility was cited for deficiencies related to expired CPR certifications among nursing staff and improper antibiotic use for a resident with a Foley catheter infection. The plan outlines corrective actions including staff education, competency assessments, and monitoring systems to ensure compliance.
Deficiencies (2)
F281 - Staffing schedule was reviewed to ensure staff had current CPR certification. Nurses with expired CPR certifications will complete re-certification classes and monitoring systems will be implemented to maintain compliance.
F315 - A Foley catheter infection was improperly treated with an antibiotic to which the microbe was not sensitive. Staff were educated on catheter care and a monitoring system for antibiotic sensitivity was implemented.
Report Facts
Plan of Correction completion date: Jul 31, 2014
Monitoring frequency: 5
Monitoring duration: 12
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Date: Jul 7, 2014
Visit Reason
The inspection was conducted as an investigation of complaints numbered 75406, 76344, and 76510 regarding the facility's compliance with professional standards and care practices.
Complaint Details
The investigation was triggered by complaints 75406, 76344, and 76510. The findings substantiated failures in CPR certification coverage and catheter care.
Findings
The facility failed to ensure that employees on each shift had current CPR certification for residents with full code status and failed to provide appropriate catheter care for a resident, resulting in a blocked catheter and inadequate antibiotic treatment.
Deficiencies (2)
F 281: The facility failed to ensure employees on each shift had current CPR certification for 12 residents with full code status, placing residents at risk during emergencies.
F 315: The facility failed to provide appropriate catheter care for a resident, resulting in a blocked urinary catheter with 1600 cc residual urine and failed to identify antibiotic resistance, delaying alternate treatment.
Report Facts
Resident census: 43
Full code residents: 12
Shifts without CPR certified staff: 20
Residual urine drained: 1600
Antibiotic treatment days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Acknowledged lack of system to identify CPR certification status | |
| Licensed nursing staff D | Reported catheter irrigation and reviewed culture sensitivity report | |
| Licensed nursing staff F | Documented resident's condition during respiratory distress | |
| Certified staff E | Notified nurse of resident's difficulty breathing | |
| Physician | Interviewed by phone, reported no memory of notification about antibiotic resistance |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 20, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously identified deficiency under regulation 483.60(a),(b) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.60(a),(b): Previously cited deficiency was corrected by the revisit date of 05/20/2014.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 20, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Richmond Healthcare.
Findings
The resident was immediately assessed for adverse side effects related to a missed medication administration, with none noted. The facility notified relevant parties, obtained physician orders, started the medication, reviewed other potentially affected residents, re-educated staff on notification procedures, and will monitor and review findings through the Quality Assurance and Assessment Committee.
Deficiencies (1)
F425-D: The resident was not administered medication as ordered. The facility assessed the resident, notified appropriate parties, obtained and started the medication, reviewed other residents, re-educated staff, and will monitor the fax machine and review findings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added the Plan of Correction | |
| Mary Jane Kennedy | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: May 14, 2014
Visit Reason
The inspection was conducted as an investigation of complaint #74492 regarding medication administration practices at the facility.
Complaint Details
The investigation was triggered by complaint #74492. The facility failed to administer prescribed medication Synthroid to a resident with hypothyroidism. The medication error was substantiated by elevated TSH lab results and admission by facility staff.
Findings
The facility failed to administer Synthroid medication as ordered by the physician for one resident with hypothyroidism from January 13, 2014, to April 10, 2014. The resident's elevated TSH levels indicated the medication omission, and the facility acknowledged the medication error.
Deficiencies (1)
F 425: The facility failed to administer Synthroid medication according to physician's orders for one resident with hypothyroidism from January 13, 2014, to April 10, 2014. The resident's medication administration records lacked the ordered medication, resulting in elevated TSH levels.
Report Facts
Resident census: 43
TSH level: 46.5
Medication dosage: 50
Medication dosage increased to: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed staff C | Acknowledged failure to follow up on thyroid medication administration. |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 6, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for 'E' level deficiencies indicating pattern deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 6, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for 'E' level deficiencies indicating pattern deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 6, 2014
Provider agreement termination date: Nov 6, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 18, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiencies were corrected by the revisit date of 03/18/2014.
Report Facts
Date of Revisit: Mar 18, 2014
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Feb 18, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#72751) regarding an incident of possible neglect involving a resident who sustained a head laceration requiring staples.
Complaint Details
The complaint investigation #72751 was substantiated as the facility did not report or investigate the incident involving resident #3's head injury.
Findings
The facility failed to thoroughly investigate and report to the state agency an incident where a resident fell and sustained a scalp injury requiring staples. The incident was unwitnessed and not reported as required by facility policy and state regulations.
Deficiencies (1)
F 225: The facility failed to investigate and report an incident of possible neglect involving a resident who sustained a head laceration requiring staples. The incident was unwitnessed and not reported to the state agency as required.
Report Facts
Resident census: 46
Number of staples: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff B | Verified the unwitnessed incident with head injury was not reported to the state agency |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 5, 2014
Visit Reason
The visit was triggered by a non-related and unsubstantiated complaint during which an un-witnessed fall resulting in injury was identified.
Complaint Details
The visit was complaint-related based on a non-related and unsubstantiated complaint. The fall incident was investigated and reported within the required timeframe after surveyor notification.
Findings
The facility investigated the un-witnessed fall with injury but initially failed to notify the State as required due to a misunderstanding. The facility has since notified the State and implemented monitoring and re-education to ensure compliance with reporting requirements.
Deficiencies (1)
F225 The facility failed to notify the State of an un-witnessed fall with injury due to a misunderstanding of the requirement. The incident occurred on 02/05/2014 and was reported on 02/13/2014 after surveyor notification.
Report Facts
Complete Date for Plan of Correction: Feb 28, 2014
Incident Date: Feb 5, 2014
Report Date: Feb 13, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Administrator who submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 31, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the facility's plan of correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.25(a)(1) and 483.25(e)(1) were corrected by the revisit date of 12/31/2013.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Date: Dec 13, 2013
Visit Reason
The inspection was conducted as a result of investigations of complaints #69034 and #70192 regarding the facility's failure to provide required restorative services.
Complaint Details
The visit was complaint-related, investigating complaints #69034 and #70192. The complaints were substantiated as the facility failed to provide ordered restorative services.
Findings
The facility failed to provide walk to dine services and range of motion exercises as ordered for residents, placing them at risk for decline in function. Staffing shortages due to a restorative aide on medical leave contributed to the failure to provide these services.
Deficiencies (2)
F 310 ADLS do not decline unless unavoidable. The facility failed to provide walk to dine services for 2 of 3 sampled residents, placing them at risk for decline in walking ability.
F 317 No reduction in range of motion unless unavoidable. The facility failed to provide range of motion exercises for 2 of 3 residents reviewed, placing them at risk for decline in range of motion.
Report Facts
Census: 47
Residents in walk to dine program: 5
Residents sampled for walk to dine: 3
Residents not provided walk to dine: 2
Restorative aide medical leave duration (weeks): 8
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 13, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation.
Findings
The facility reinstated a full-time Restorative Aide on 12/13/13 to provide services to all residents on the restorative aide program. The Director of Nursing and Assistant Director of Nursing will monitor and audit the restorative aide program to ensure compliance and appropriate service delivery.
Deficiencies (3)
F0000: This Plan of Correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. Statement of Deficiencies have been or will be taken to the facility's Quality Assurance/Assessment Committee.
F310-D: The facility reinstated a full-time Restorative Aide on 12/13/13 to provide services to all residents on the restorative aide program and began performing services on that date.
F317-D: The facility reinstated a full-time Restorative Aide on 12/13/13 to provide services to all residents on the restorative aide program and began performing services on that date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 12, 2013
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 09/12/2013. No other deficiencies or findings are listed.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited under ID prefix S0600 was corrected on 09/12/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 12, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 12, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory requirements.
Report Facts
Deficiencies corrected: 14
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 1
Date: Aug 13, 2013
Visit Reason
The inspection was conducted to assess compliance with dietary services regulations, specifically focusing on staffing and sanitation in the dietary department.
Findings
The facility failed to employ a full-time certified dietary manager and maintain a clean and sanitary dietary department. Observations included a microwave oven with dried food spatters, serving scoops and steam table pans stored with visible water drops, and limited space for air drying dishes.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to employ a full-time certified dietary manager to assure residents a clean and sanitary dietary department. Observations revealed unclean microwave oven surfaces and improperly stored serving utensils with visible water.
Report Facts
Resident census: 45
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Aug 13, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection. It outlines corrective actions to address identified issues and ensure compliance with federal Medicare and Medicaid requirements.
Findings
The Plan of Correction details multiple deficiencies related to anticoagulant therapy management, individualized activity programs, facility maintenance, care plan development, medication storage, dietary services, and equipment maintenance. The facility has implemented monitoring, staff education, and corrective actions to address these issues.
Deficiencies (14)
F225-D: Resident #34 and #40 were reassessed due to lack of thorough investigation of anticoagulant therapy incidents. Facility will monitor Coumadin logs and provide staff education to prevent omissions.
F248-E: Residents #26, #37, #13, and #35 were reassessed and individualized activity programs were developed. Ongoing monitoring of activity programs will be conducted.
F253-E: Maintenance issues including discolored floor tiles, marred walls, and ceiling stains were identified and corrective actions scheduled. Facility will monitor physical plant cleanliness and maintenance.
F279-D: Residents #55 and #58 care plans were reviewed to ensure comprehensive individualized plans. Staff education and weekly monitoring will be conducted.
F280-D: Care plans for residents #33 and #57 were revised to address catheter leg bag use. Staff education and monitoring planned.
F309-D: Resident #34's Coumadin dosage and related records were reviewed. Facility will monitor anticoagulant administration and educate staff on potential drug interactions.
F312-D: Resident #58 had toenail care addressed. Staff will monitor hygiene issues and provide education on nail care procedures.
F315-D: Residents #33, #49, and #55 care plans were reviewed and revised for urinary catheter and toileting schedules. Staff education on peri care will be provided.
F323-E: Chemicals were secured behind locked doors to prevent accident hazards. Staff education and monitoring of chemical storage will continue.
F366-E: Dietary Manager notified residents about meal substitutes and alternates. Staff education and resident interviews will monitor awareness of meal options.
F371-F: Microwave cleaning schedule implemented. Staff educated on proper storage of utensils and ongoing monitoring established.
F431-D: Medications were secured and logged properly. Staff education on drug storage and access will be provided. Monitoring of medication areas planned.
F456-B: Whirlpool bath motor replaced and functioning. Staff educated on maintenance request procedures and equipment monitoring.
S600-F: Dietary Manager to enroll in certification program. Dietary procedures will be reviewed and monitored regularly. Microwave cleaning schedule maintained.
Report Facts
Monitoring frequency: 5
Monitoring frequency: 7
Monitoring frequency: 3
Monitoring frequency: 5
Monitoring frequency: 3
Monitoring frequency: 2
Monitoring frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted Plan of Correction and involved in staff education and monitoring oversight |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 10, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as of the revisit date.
Findings
The report confirms that the deficiency identified under regulation 483.25(a)(3) was corrected by 07/03/2013. No other deficiencies or issues were noted.
Deficiencies (1)
Regulation 483.25(a)(3) deficiency was corrected as of 07/03/2013.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 10, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as of the revisit date.
Findings
The report confirms that the deficiency identified under regulation 483.25(a)(3) was corrected by 07/03/2013. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(a)(3) deficiency was corrected as of 07/03/2013.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 24, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey conducted at the facility.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey.
Findings
The facility implemented corrective actions to address oral care deficiencies, including providing oral care multiple times daily, conducting oral assessments, scheduling dental appointments, re-educating nursing staff, and establishing quality assurance monitoring systems.
Deficiencies (1)
F312-G: Residents were provided oral care three times daily and again at bedtime during observation. Administrative nursing staff completed oral assessments and scheduled dental care as needed.
Report Facts
Complete Date: Jun 28, 2013
Complete Date: Jul 1, 2013
Complete Date: Jul 2, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added the Plan of Correction | |
| Mary Jane Kennedy | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Jun 20, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#66430) regarding concerns about oral care provided to dependent residents at Richmond Healthcare & Rehab Center.
Complaint Details
The visit was triggered by complaint investigation #66430 concerning inadequate oral care for dependent residents.
Findings
The facility failed to provide appropriate and consistent oral care to four dependent residents, resulting in poor dental hygiene, including plaque build-up and bleeding gums for resident #1. Documentation of oral care was frequently incomplete or missing, and staff interviews revealed inconsistent monitoring and performance of oral hygiene tasks.
Deficiencies (1)
F 312: The facility failed to provide necessary oral care to dependent residents, resulting in poor dental hygiene and bleeding gums for resident #1 despite care plans and physician recommendations.
Report Facts
Resident census: 44
Residents reviewed for dental status: 4
Days lacking oral care documentation: 19
Days lacking oral care documentation: 25
Days lacking oral care documentation: 14
Days lacking oral care documentation: 9
Days lacking oral care documentation: 7
Days lacking oral care documentation: 2
Days lacking oral care documentation: 8
Days lacking oral care documentation: 6
Days lacking oral care documentation: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 31, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a revisit inspection.
Findings
The Dietary Manager is currently enrolled in a State of Kansas approved Dietary Manager course and is supported by a contracted Registered Dietician. The Dietary Manager is expected to take the certification exam in October 2012.
Deficiencies (1)
S0600-C: Current residents have the potential to be affected due to issues related to dietary management. The Dietary Manager is enrolled in a state-approved course and will take the exam in October 2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies had been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected by 05/30/2012 as documented in this revisit report.
Report Facts
Deficiency correction completion date: May 30, 2012
Follow-up survey completion date: May 4, 2012
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies were corrected as of 05/30/2012, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency corrections completed: 14
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of 05/30/2012, as documented in the report.
Report Facts
Deficiencies corrected: 14
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 1
Date: Jul 2, 2012
Visit Reason
The inspection was conducted to evaluate compliance with state regulations regarding dietary services and staffing requirements at Richmond Healthcare & Rehab Center.
Findings
The facility failed to maintain the services of an onsite certified dietary manager as required by state regulations. The current dietary staff was enrolled in a state-approved Dietary Manager course but was not yet certified.
Deficiencies (1)
28-39-158(a) Dietary Services: The facility failed to provide an onsite certified dietary manager as required by state regulations. The dietary staff was enrolled in a certification course but had not yet passed the state exam.
Report Facts
Resident census: 44
Inspection Report
Plan of Correction
Deficiencies: 12
Date: May 30, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during an annual survey inspection.
Findings
The facility identified multiple deficiencies related to resident notification, care planning, equipment maintenance, medication administration, kitchen environment, and facility repairs. The Plan of Correction outlines corrective actions including staff re-education, equipment orders, care plan updates, facility repairs, and ongoing monitoring to ensure compliance.
Deficiencies (12)
F157-D: The facility failed to assure timely notification of changes in residents' conditions to responsible parties. Licensed nursing staff will be re-educated and monitoring will be conducted to ensure compliance.
F248-D: The facility failed to update care plans to include appropriate sensory stimulation and activities for residents with decreased participation. The interdisciplinary team will review and revise care plans and receive re-education.
F253-E: The facility had maintenance issues including damaged wheelchair parts, walls, carpets, and shower areas. Repairs and replacements are scheduled with ongoing monitoring.
F279-D: Care plans for multiple residents were not updated timely for discharge planning, ambulation, and activity preferences. Staff will be re-educated and care plans monitored weekly.
F280-D: The facility failed to adequately assess and plan for residents' fall risks and discharge potential. Care plans will be updated and staff educated on timely response to safety alarms.
F311-D: Equipment for resident #51 was not obtained timely. The facility ordered equipment immediately and will monitor new orders and audits.
F323-D: Equipment for resident #35 was not obtained timely. The facility ordered equipment immediately and will monitor new orders and audits.
F325-G: The facility failed to properly identify and document fortified food plans and supplement administration for residents at risk of unintended weight loss. Staff will be re-educated and monitoring implemented.
F329-D: Medication errors occurred related to PRN and antihypertensive medications. Staff were re-educated and monitoring of medication administration and documentation will be conducted.
F371-F: The kitchen environment had sanitation and maintenance issues including unclean equipment and improper food storage. Immediate cleaning was done and staff re-educated with ongoing monitoring planned.
F428-D: Medication documentation and error policies were not followed for residents receiving PRN and antihypertensive medications. Staff re-education and monitoring are in place.
F465-E: The kitchen hopper was repaired and the facility plans kitchen and dining room renovations including ceiling repair and flooring replacement. Maintenance monitoring will continue.
Report Facts
Plan of Correction completion date: May 30, 2012
Monitoring frequency: 5
Monitoring frequency: 3
Monitoring frequency: 4
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 2
Date: May 4, 2012
Visit Reason
The visit was conducted to assess compliance with dietary services regulations, focusing on the cleanliness and sanitary conditions of the dietary department.
Findings
The facility failed to maintain a clean and sanitary dietary department, including food storage, preparation, and service areas. Observations revealed undated and unlabeled food items, dirty kitchen equipment, and inadequate cleaning practices, along with the absence of a certified dietary manager.
Deficiencies (2)
28-39-158(a) Dietary services. The facility failed to maintain a clean and sanitary dietary department for food storage, preparation, and service. Observations included undated and unlabeled food items in the refrigerator and dirty kitchen equipment with food debris.
The facility failed to maintain the services of a certified dietary manager to ensure proper supervision and sanitation in the dietary department.
Report Facts
Resident census: 48
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N030003 POC CBOR11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as ASPEN with State ID N030003.
Findings
No deficiency records or findings are included in this Plan of Correction document. It serves as a corrective action response to a previous inspection.
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