Inspection Reports for Recover-Care Richmond LLC
340 E. SOUTH STREET, RICHMOND, KS, 66080-4021
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 18, 2016, found that all previously cited deficiencies had been corrected, with no outstanding issues noted at that time. Earlier inspections showed a pattern of deficiencies primarily related to dietary services, including failure to retain a certified dietary manager and sanitation problems in the kitchen, as well as issues with resident care documentation, medication administration, and facility maintenance. Complaint investigations substantiated failures in oral care, restorative services, catheter care, and timely medication administration, some of which led to resident harm or risk. Enforcement actions included denial of payment for new Medicare admissions at times, but no fines or license suspensions were listed in the available reports. The facility’s record shows improvement over time, with repeated revisits confirming correction of prior deficiencies and substantial compliance achieved by the most recent survey.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
33.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
457% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
48 residents
Based on a February 2016 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 10
Date: Mar 18, 2016
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 have been corrected.
Findings
All previously cited deficiencies listed by regulation numbers were marked as corrected and completed as of the revisit date.
Deficiencies (10)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.10(c)(6)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(g)-(j)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(c)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.70(f)
Deficiency related to regulation 483.75(l)(1)
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Mar 18, 2016
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that previously cited deficiencies have been corrected as of the revisit date, with specific reference to regulation 28-39-158(a).
Deficiencies (1)
Deficiency related to regulation 28-39-158(a) previously cited and corrected
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 deficiencies cited in a prior inspection report (2567). It outlines corrective actions to address identified deficiencies.
Findings
The plan addresses multiple deficiencies including failure to notify Durable Power of Attorney on resident transfers, improper handling of resident funds, sanitation and maintenance issues, inaccurate resident assessments and coding, medication administration monitoring, dietary service deficiencies, and malfunctioning call lights. Corrective actions include re-education, monitoring logs, repairs, audits, and ongoing oversight by facility leadership.
Deficiencies (11)
Failure to notify Durable Power of Attorney on resident transfer
Improper handling of resident funds
Sanitation and maintenance issues including unclean toilets, rusted fixtures, and slow drains
Inaccurate resident assessments and coding related to pressure ulcers and PASRR screening
Failure to provide treatment per physician orders for residents with pressure ulcers
Noncompliance with vital sign policy and medication administration documentation
Dietary deficiencies including missing food items and unsanitary kitchen conditions
Unsanitary kitchen equipment and expired food supplements
Malfunctioning call lights on resident halls
Improper medical record management and chart organization
Dietary manager lacking certification
Report Facts
Affected residents with fund refund: 3
Call lights replaced: 4
Monitoring periods: 4
Expected certification completion: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Director of Nursing | Named repeatedly in relation to re-education, monitoring, and corrective actions | |
| Business Office Manager | Responsible for refunding resident funds and monitoring | |
| Maintenance Director | Responsible for repairs and monitoring maintenance issues | |
| Dietary Manager | Responsible for dietary education, monitoring, and certification progress |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 24, 2016
Visit Reason
A Health survey was conducted to determine if the facility is 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 and plan of correction.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and provided contact information related to the survey findings. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 9
Date: Feb 24, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #83533 and #95619.
Complaint Details
The visit included complaint investigations #83533 and #95619 as part of a Health Resurvey.
Findings
The facility failed to retain a full-time certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department. Multiple sanitation issues were observed in the kitchen and dining areas, including unclean equipment, food storage concerns, and inadequate cleaning of dining tables.
Deficiencies (9)
Failure to retain a full-time certified dietary manager to oversee dietary staff and maintain sanitation.
Oven floor held darkened food spillage and crumbs.
Refrigerator contained liquid supplements lacking dates and shelves with spills/debris.
Non-stick surfaces on skillets and grill were buckled and coming off, with soiled buildup.
Sheet pans held brown colored debris in corners.
Ceiling vents over stove had visible dust buildup hanging down.
Hot food cart held visible food crumbs in bottom drawer.
Nail care performed on dining table without cleaning table before meal service.
Staff lacked knowledge of required wet time for disinfectant spray used on tables.
Report Facts
Census: 48
Wet time for disinfectant: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary staff I | Department Manager (not certified) | Reported working as manager but was not certified and did not complete certification class. |
| Dietary staff J | Dietary Staff | Verified areas in kitchen needed cleaning. |
| Maintenance staff K | Maintenance Staff | Reported not cleaning ceiling vents, thought dietary staff did. |
| Direct care staff H | Direct Care Staff | Performed nail care on resident at dining table and reported cleaning table with disinfectant before lunch. |
| Direct care staff P | Direct Care Staff | Set tables for meal service and reported tables are wiped with disinfectant before meals. |
| Direct care staff Q | Direct Care Staff | Reported use of disinfectant spray Virex on tables but unsure of required wet time. |
| Direct care staff D | Direct Care Staff | Reported no training on required wet time for disinfectant spray. |
| Housekeeping staff R | Housekeeping Staff | Reported disinfectant Virex 112-56 requires 10 minutes wet time and nursing staff do not attend housekeeping training. |
| Administrative nursing staff A | Administrative Nursing Staff | Unaware staff lacked knowledge of disinfectant wet time. |
| Administrative staff N | Administrative Staff | Reported dietary staff I served as department manager but was not certified and failed to complete certification class. |
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 to be at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Deficiencies cited at "F" level with no harm but potential for more than minimal harm that is not immediate jeopardy.
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. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 19, 2015
Visit Reason
This Plan of Correction document serves as a written allegation of substantial compliance with Federal Medicare and Medicaid requirements and outlines corrective actions related to deficiencies identified in a prior inspection.
Findings
The facility administrator identified a Certified Dietary Manager program at the University of North Dakota and plans for the Dietary Manager to enroll and complete the 270-hour certification program under the guidance of a Registered Dietician, with progress monitored quarterly by the facility's Quality Assurance and Assessment Committee.
Deficiencies (1)
Dietary Manager certification program enrollment and completion plan
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 cited deficiencies at Richmond Healthcare & Rehab Center.
Findings
The report documents that the previously reported deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 01/19/2015.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously cited
Report Facts
Deficiency correction date: Jan 19, 2015
Inspection Report
Follow-Up
Deficiencies: 17
Date: Jan 12, 2015
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
The report documents that all previously identified deficiencies were corrected as of 12/14/2014, with no uncorrected deficiencies noted at the time of the revisit.
Deficiencies (17)
Deficiency related to regulation 483.10(i)(1)
Deficiency related to regulation 483.10(k),(l)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(c)(6)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(b)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(a)(3)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(k)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.55(b)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 17
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 1
Date: Jan 12, 2015
Visit Reason
This visit was a non-compliant revisit to assess compliance with dietary services regulations.
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)
Failure to retain the services of a certified dietary manager to perform managerial duties overseeing dietary staff and maintaining a clean and sanitary dietary department.
Report Facts
Census: 42
Inspection Report
Plan of Correction
Deficiencies: 17
Date: Nov 24, 2014
Visit Reason
This document is a Plan of Correction submitted by Richmond Healthcare and Rehabilitation Center addressing deficiencies cited in a prior inspection report.
Findings
The Plan of Correction details immediate actions taken, identification of other residents potentially affected, systems put in place to prevent recurrence, and monitoring plans for multiple deficiencies related to mail delivery, personal property loss, resident addressing preferences, facility maintenance, care planning, hospice coordination, grooming, bowel and bladder care, incident management, prosthetic care, medication management, dietary services, dental referrals, and laundry services.
Deficiencies (17)
Untimely delivery of mail to residents
Theft and loss of personal property
Use of terms of endearment instead of residents' given names
Failure to document and follow up on resident council requests
Facility maintenance issues including broken floor tiles, plumbing, and cleanliness
Incomplete care area assessments for residents
Care plan updates not reflecting recent incidents and accidents
Coordination of care with hospice services
Inadequate grooming and oral care
Inadequate bowel and bladder assessments and care
Staff education on incident and accident management and elopement policy
Prosthetic care and skin integrity monitoring
Monitoring of standing orders and bowel movement documentation
Dietary staff hygiene and food temperature control
Dental referrals and social service updates
Medication regimen review and follow-up
Laundry and textile handling and staff education
Report Facts
Deficiency count: 17
Monitoring duration: 12
Monitoring frequency: 5
Monitoring frequency: 2
Monitoring duration: 8
Monitoring duration: 4
Monitoring duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Removed sign in resident room and educated staff on addressing residents | |
| Director of Nursing | DON | Provided education and monitoring for multiple deficiencies including care planning, hospice coordination, grooming, bowel and bladder care, prosthetic care, medication management |
| Administrator | Provided education, monitored grievance logs, resident council follow-up, and dietary compliance | |
| Maintenance Director | Addressed multiple maintenance deficiencies and educated housekeeping and laundry staff | |
| Dietary Manager | Managed dietary staff hygiene, food temperature control, and cleaning schedules | |
| Director of Professional Services | Educated Director of Nursing on care area assessments and medication recommendations | |
| Health Information Management Director | Monitored admission documentation for resident preferences | |
| Director of Rehabilitation | Reviewed resident census for prosthetic care monitoring | |
| Assistant Business Office Manager | ABOM | Monitored mail delivery compliance |
| Social Service Designee | Educated on dental referrals and social service updates |
Inspection Report
Annual Inspection
Deficiencies: 1
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, indicating significant noncompliance. Enforcement remedies including denial of payment for new Medicare admissions were imposed effective February 14, 2015, with potential termination if substantial compliance is not achieved within six months.
Deficiencies (1)
Most serious deficiencies found at an "F" level
Report Facts
Months until recommended termination: 6
Denial of payment effective date: Feb 14, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Named as facility administrator in the report header. |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter. |
| Joe Ewert | Commissioner | Commissioner of Kansas Department for Aging and Disability Services, recipient of informal dispute resolution requests. |
| Janice VanGotten | Regional Manager | Copied on the report. |
| Audrey Sunderraj | Director | Copied on the report. |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 16
Date: Nov 14, 2014
Visit Reason
The inspection was a Health Resurvey and complaint investigations #79277 and #79675.
Complaint Details
The inspection included complaint investigations #79277 and #79675.
Findings
The facility was found deficient in multiple areas including residents' rights to privacy and prompt mail delivery, telephone access with privacy, dignity and respect, grievance follow-up, housekeeping and maintenance, comprehensive assessments, care planning, hospice care coordination, ADL care, urinary incontinence management, fall prevention, prosthesis care, unnecessary drug use, dental services, drug regimen review, and infection control related to laundry handling.
Deficiencies (16)
Facility failed to ensure residents promptly received mail on weekends.
Facility failed to ensure one resident retained their personal property and failed to investigate missing items.
Facility failed to promote care in a dignified manner for residents, including posting personal care instructions in resident rooms and staff using terms of endearment instead of residents' given names.
Facility failed to act upon grievances and recommendations voiced from residents during resident council meetings.
Facility failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable environment, including broken floor tiles, damaged furniture, rust, and unsanitary bathrooms.
Facility failed to complete comprehensive assessments for residents including urinary incontinence and ADL/functional rehabilitation.
Facility failed to review and revise care plans for residents after accidents and falls, including failure to implement interventions to prevent additional falls.
Facility failed to coordinate hospice care services and document hospice visits and equipment for a resident receiving hospice care.
Facility failed to provide necessary services to maintain good grooming and oral hygiene for residents, including failure to provide nail care after showers and inadequate oral care.
Facility failed to provide proper treatment and care for a resident's prosthesis, including failure to ensure proper fitting and follow-up with prosthetic company.
Facility failed to ensure urinary incontinent resident received appropriate treatment and services to restore bladder function and failed to provide adequate perineal care after incontinence.
Facility failed to provide adequate supervision and assistive devices to prevent falls for residents identified as fall risks, failed to respond to alarms, and failed to develop interventions after falls.
Facility failed to maintain a clean and sanitary dietary department, including improper hair coverings, undated and unlabeled food items, dirty kitchen equipment, and improper food handling.
Facility failed to ensure dental services were available and offered to a resident with dentures needing adjustment.
Facility failed to conduct monthly drug regimen review for a resident and failed to follow up on pharmacist's recommendation for dose reduction of an antipsychotic medication.
Facility failed to maintain sanitary environment and prevent infection during laundry handling, including uncovered laundry carts, soiled laundry on floor, and lack of appropriate PPE.
Report Facts
Residents reviewed: 19
Residents census: 38
Fall risk score: 8
Fall risk score: 19
Days without bowel movement: 5
Days without toileting opportunity: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff BB | Administrative Staff | Named in mail delivery deficiency. |
| Staff CC | Licensed Staff | Named in mail delivery and dignity deficiency. |
| Staff F | Social Service Staff | Named in personal property grievance deficiency. |
| Staff P | Licensed Nursing Staff | Named in dignity and fall prevention deficiencies. |
| Staff V | Direct Care Staff | Named in dignity and urinary incontinence deficiencies. |
| Staff W | Direct Care Staff | Named in mail delivery, dignity, and urinary incontinence deficiencies. |
| Staff Y | Licensed Staff | Named in urinary incontinence and fall prevention deficiencies. |
| Staff E | Activity Staff | Named in grievance and nail care deficiencies. |
| Staff L | Direct Care Staff | Named in dignity, fall prevention, and food service deficiencies. |
| Staff S | Direct Care Staff | Named in urinary incontinence and fall prevention deficiencies. |
| Staff T | Direct Care Staff | Named in urinary incontinence and fall prevention deficiencies. |
| Staff U | Direct Care Staff | Named in urinary incontinence and bowel monitoring deficiencies. |
| Staff CC | Licensed Nursing Staff | Named in dental services deficiency. |
| Staff F | Social Service Staff | Named in dental services deficiency. |
| Staff AA | Consultant Pharmacy Staff | Named in drug regimen review deficiency. |
| Staff N | Licensed Nursing Staff | Named in elopement and fall prevention deficiencies. |
| Staff B | Licensed Administrative Staff | Named in elopement, fall prevention, and drug regimen review deficiencies. |
| Staff C | Licensed Administrative Staff | Named in elopement and fall prevention deficiencies. |
| Staff J | Direct Care Staff | Named in prosthesis care deficiency. |
| Staff M | Contract Direct Care Staff | Named in hospice care coordination deficiency. |
| Staff O | Hospice Licensed Nursing Staff | Named in hospice care coordination deficiency. |
| Staff P | Licensed Nursing Staff | Named in hospice care coordination and fall prevention deficiencies. |
| Staff D | Dietary Staff | Named in food service sanitation deficiency. |
| Staff EE | Dietary Staff | Named in food service sanitation deficiency. |
| Staff R | Direct Care Staff | Named in food service sanitation and urinary incontinence deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 3, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report shows that the deficiencies identified under regulations 483.20(k)(3)(i) and 483.25(d) were corrected as of 08/06/2014.
Deficiencies (2)
Deficiency related to regulation 483.20(k)(3)(i)
Deficiency related to regulation 483.25(d)
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 conducted on 2014-07-14.
Complaint Details
This plan of correction is in response to deficiencies cited during a complaint survey.
Findings
The plan addresses deficiencies related to expired CPR certifications among nursing staff and improper antibiotic treatment for a resident with a plugged Foley catheter. The facility implemented staff education, monitoring systems, and competency assessments to prevent recurrence and ensure compliance.
Deficiencies (2)
Staff did not have current Cardiopulmonary Resuscitation (CPR) certification on file.
Inappropriate antibiotic prescribed for resident with plugged Foley catheter due to lack of sensitivity to the microbe.
Report Facts
Dates of corrective actions: Jul 11, 2014
Dates of corrective actions: Jul 31, 2014
Dates of corrective actions: Aug 6, 2014
Monitoring frequency: 5
Monitoring duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 7, 2014
Visit Reason
An abbreviated 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 deficiency in the facility to be a 'G' level deficiency, resulting in enforcement remedies including denial of payment for new Medicare admissions effective October 7, 2014.
Deficiencies (1)
Most serious deficiency found was a 'G' level deficiency
Report Facts
Denial of payment effective date: Oct 7, 2014
Termination recommendation date: Jan 7, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact person for questions and informal dispute resolution |
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 requirements.
Complaint Details
The investigation was triggered by complaints 75406, 76344, and 76510. The findings substantiated failures in CPR certification coverage and catheter care leading to resident harm.
Findings
The facility failed to ensure employees on each shift had current CPR certification for residents with full code status, placing residents at risk. Additionally, the facility failed to provide appropriate catheter care for a resident, resulting in hospitalization due to a blocked catheter and inadequate antibiotic treatment for a urinary tract infection.
Deficiencies (2)
Facility failed to ensure employees on each shift had current CPR certification for 12 residents with full code status.
Facility failed to provide appropriate catheter care for a resident, resulting in blocked catheter and inadequate antibiotic treatment.
Report Facts
Census: 43
Full code residents: 12
Shifts without CPR certified staff: 20
Residual urine drained: 1600
Antibiotic dosage: 250
Lasix dosage: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported 12 full code residents currently residing in the facility | |
| Licensed nursing staff C | Acknowledged lack of system to identify CPR certified staff and failed to find physician progress note | |
| Licensed nursing staff D | Reported catheter irrigation practices and reviewed lab results related to antibiotic resistance | |
| Licensed nursing staff F | Responded to resident's respiratory distress during incident | |
| Certified staff E | Notified licensed nurse of resident's difficulty breathing | |
| Physician | Interviewed by phone, reported no memory of notification regarding antibiotic resistance |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 20, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.60(a),(b) with ID prefix F0425 was corrected as of 05/20/2014.
Deficiencies (1)
Deficiency under regulation 483.60(a),(b) previously cited with ID prefix F0425
Report Facts
Deficiencies corrected: 1
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 cited in a complaint investigation at Richmond Healthcare.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by event ID ISWK11 and complaint ID 051414.
Findings
The Plan of Correction addresses a medication administration deficiency where a resident did not receive medication on time. The facility assessed the resident for adverse effects, notified relevant parties, obtained physician orders, and re-educated staff on notification procedures.
Deficiencies (1)
Failure to administer medication as ordered resulting in a resident not receiving medication on time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction. |
| Mary Jane Kennedy | Modified the Plan of Correction. | |
| Irina Strakhova | Added 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
Investigation of complaint #74492 found substantiated failure to administer prescribed Synthroid medication to a resident with hypothyroidism from 1/13/14 to 4/10/14.
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, despite having the diagnosis and physician's order. The medication error was identified after elevated TSH lab results and acknowledged by facility staff and the physician's office.
Deficiencies (1)
Failed to administer medications according to physician's orders for one resident with hypothyroidism.
Report Facts
Resident census: 43
TSH laboratory test result: 46.5
Medication dosage: 50
Medication dosage increase: 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 by the State Fire Marshal's Office 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 and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Deficiencies (1)
Deficiencies found at 'E' level, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Aug 6, 2014
Effective date for provider agreement termination: Nov 6, 2014
IDR request timeframe: 10
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 deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) identified as F0225 was corrected as of 03/18/2014.
Deficiencies (1)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) previously cited as F0225
Report Facts
Deficiency correction date: 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 the facility's failure to thoroughly investigate and report an incident of possible neglect involving a resident who sustained a head laceration requiring staples.
Complaint Details
The complaint investigation (#72751) found that the facility did not report or thoroughly investigate an unwitnessed fall resulting in a head injury requiring staples for resident #3.
Findings
The facility failed to investigate and report to the state agency an unwitnessed incident where a resident fell and sustained a scalp injury requiring 7 staples. The resident had severe cognitive impairment and was at risk for falls. The incident was not reported as required by facility policy.
Deficiencies (1)
Failure to thoroughly investigate and report an incident of possible neglect related to a resident who received a head laceration with staples.
Report Facts
Resident census: 46
Staples to scalp: 7
Selected residents for review: 3
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 occurred in response to a non-related and unsubstantiated complaint during which an un-witnessed fall resulting in injury was identified. The report addresses the facility's failure to notify the State promptly about the incident.
Complaint Details
The visit was triggered by a non-related and unsubstantiated complaint. The incident of the un-witnessed fall was discovered during this visit. The complaint itself was unsubstantiated.
Findings
The facility investigated the un-witnessed fall with injury but initially failed to notify the State due to a misunderstanding of reporting requirements. Upon surveyor notification, the facility immediately reported the incident and re-educated staff on notification procedures. The Administrator will monitor incident reports for compliance over the next 30 days.
Deficiencies (1)
Failure to notify the State of an un-witnessed fall with injury in a timely manner.
Report Facts
Incident date: Feb 5, 2014
Report date: Feb 13, 2014
Monitoring frequency: 5
Monitoring duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Named as submitting the Plan of Correction and responsible for monitoring compliance |
| Shirley Boltz | Regional QA Nurse | Provided re-education to the DON and Administrator on State notification requirements |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 31, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and 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.
Deficiencies (2)
Deficiency related to regulation 483.25(a)(1)
Deficiency related to regulation 483.25(e)(1)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 13, 2013
Visit Reason
This Plan of Correction document addresses deficiencies identified in a complaint investigation and outlines corrective actions taken by the facility to achieve substantial compliance with Federal Medicare and Medicaid requirements.
Complaint Details
This Plan of Correction is related to a complaint investigation as indicated by the reference to 'Richmond 121313 Complaint'.
Findings
The facility reinstated a full-time Restorative Aide on 12/13/2013 to provide services to all residents on the restorative aide program. The Director and Assistant Director of Nursing began reviewing residents to determine restorative service needs and will monitor and audit the program to ensure compliance.
Deficiencies (2)
Failure to provide adequate restorative services to residents as identified in the restorative aide program.
Failure to properly monitor and document restorative aide services for residents.
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: 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 ordered restorative services.
Complaint Details
The visit was triggered by complaints #69034 and #70192. The complaints were substantiated as the facility failed to provide restorative services as ordered, leading to risk of decline in residents' functional abilities.
Findings
The facility failed to provide walk to dine and range of motion restorative services as ordered for residents #01 and #03, placing them at risk for decline in ability to walk and range of motion. Staffing shortages due to a restorative aide on medical leave contributed to the failure to provide these services.
Deficiencies (2)
Failure to provide walk to dine services as ordered for residents #01 and #03.
Failure to provide range of motion restorative services as ordered for residents #01 and #03.
Report Facts
Census: 47
Residents in walk to dine program: 5
Residents sampled in walk to dine program: 3
Restorative aide medical leave duration: 8
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 12, 2013
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were 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 issues were noted in this revisit report.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously cited
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 12, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers have been corrected as of the revisit date.
Report Facts
Deficiencies corrected: 15
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 regulatory inspection, outlining corrective actions to achieve compliance with Federal Medicare and Medicaid requirements.
Findings
The Plan of Correction addresses multiple deficiencies including anticoagulant therapy management, individualized activity programs, facility maintenance issues, care plan development, medication storage, chemical safety, dietary services, and equipment maintenance. The facility outlines reassessments, staff education, monitoring schedules, and Quality Assurance Committee reviews to ensure sustained compliance.
Deficiencies (14)
Lack of thorough investigation and omission in anticoagulant therapy administration
Failure to provide individualized activity programs meeting residents' needs
Maintenance issues including discolored flooring, marred walls, door repairs, ceiling stains, and air vent cleaning
Incomplete or inadequate individualized comprehensive care plans
Care plans not addressing use of catheter leg bags
Issues with Coumadin dosage review and monitoring
Inadequate nail care and hygiene monitoring
Lack of proper anchoring device for urinary catheter and incomplete care plans for incontinent residents
Improper storage of chemicals posing accident hazards
Failure to provide meal alternates and inform residents adequately
Unsanitary microwave and improper storage of kitchen utensils and pans
Improper medication storage and lack of locked compartments for controlled drugs
Malfunctioning whirlpool bath motor and lack of maintenance request procedures
Dietary Manager lacking certification and ongoing monitoring of dietary procedures
Report Facts
Monitoring frequency: 5
Monitoring frequency: 7
Monitoring frequency: 3
Monitoring frequency: 5
Monitoring frequency: 5
Monitoring frequency: 3
Monitoring frequency: 2
Monitoring frequency: 2
Monitoring frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Administrator submitting the Plan of Correction and involved in education and monitoring |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction |
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 1
Date: Aug 13, 2013
Visit Reason
The inspection was conducted to evaluate compliance with dietary services regulations, specifically to assess whether the facility employed a full-time certified dietary manager and maintained a clean and sanitary dietary department.
Findings
The facility failed to employ a full-time certified dietary manager to ensure residents received proper dietary services. Observations revealed sanitation issues including a microwave oven with dried food spatters, serving scoops and steam table pans stored with visible water droplets, and insufficient space for air drying dishes due to remodeling.
Deficiencies (1)
Failure to employ a full-time certified dietary manager to assure a clean and sanitary dietary department.
Report Facts
Census: 45
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 10, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously cited deficiency with ID prefix F0312 related to regulation 483.25(a)(3) was corrected as of 07/03/2013.
Deficiencies (1)
Deficiency previously cited under regulation 483.25(a)(3) was corrected.
Report Facts
Deficiency correction date: Jul 3, 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 identified deficiencies related to oral care for residents, including inadequate oral care provision and assessment. The plan outlines corrective actions such as re-education of nursing staff, oral assessments, scheduling dental appointments, and ongoing monitoring and documentation improvements.
Deficiencies (1)
Inadequate oral care provided to residents and insufficient oral assessments.
Report Facts
Complete Date for Plan of Correction: Jun 28, 2013
Oral assessments conducted: 100
Oral care walking rounds monitoring frequency: 5
Duration of monitoring: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Bellinger | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Added the Plan of Correction | |
| Mary Jane Kennedy | Modified the Plan of Correction | |
| Director of Nursing | Director of Nursing | Responsible for re-educating nursing staff on oral care policies and procedures |
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 inadequate oral care provided to dependent residents.
Complaint Details
The complaint investigation #66430 was substantiated with findings that the facility failed to provide adequate oral care to residents, as evidenced by observations, record reviews, and interviews.
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. Documentation of oral care was frequently missing or incomplete, and staff interviews revealed inconsistent monitoring and performance of oral hygiene tasks.
Deficiencies (1)
Failure to provide appropriate oral care to dependent residents resulting in poor dental hygiene and bleeding gums.
Report Facts
Residents reviewed for dental status: 4
Census: 44
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: 6
Days lacking oral care documentation: 8
Days lacking oral care documentation: 6
Days lacking oral care documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Participated in phone conference with DPOA regarding oral care concerns. | |
| Physician A | Physician | Provided dental evaluation and treatment recommendations for Resident #1. |
| Licensed Nursing Staff E | Observed providing oral care and reported monitoring CNA charting. | |
| Direct Care Staff C | Observed providing oral care to Resident #1 and reported oral care practices. | |
| Direct Care Staff D | Observed providing oral care to Resident #1 and Resident #2. | |
| Direct Care Staff G | Reported oral care practices and documentation. | |
| Direct Care Staff H | Observed providing oral care to Resident #1 and Resident #2. | |
| Administrative Nursing Staff B | Reported awareness of oral care problems and auditing efforts. |
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 plan addresses a deficiency related to the Dietary Manager's qualifications and ongoing education, with corrective actions including enrollment in a state-approved course and consultation with a Registered Dietician.
Deficiencies (1)
Dietary Manager qualifications and ongoing education
Report Facts
Plan of Correction completion date: Jul 31, 2012
Inspection Report
Follow-Up
Deficiencies: 12
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
The report shows that all previously identified deficiencies were corrected by 05/30/2012 as documented by the correction completion dates for each cited regulation.
Deficiencies (12)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(a)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.70(h)
Report Facts
Deficiencies corrected: 12
Inspection Report
Follow-Up
Deficiencies: 12
Date: Jul 2, 2012
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously cited deficiencies were corrected by 05/30/2012 as documented by the correction completion dates for each regulation cited.
Deficiencies (12)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(f)(1)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(a)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.70(h)
Report Facts
Deficiencies corrected: 12
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 1
Date: Jul 2, 2012
Visit Reason
The inspection was conducted to assess compliance with state regulations regarding dietary services, specifically the requirement for an onsite certified dietary manager.
Findings
The facility failed to provide an onsite certified dietary manager as required by state regulations. The current dietary staff was enrolled in a dietary manager course but was not yet certified and scheduled to take the certification exam in October 2012.
Deficiencies (1)
Failure to provide an onsite certified dietary manager as required by state regulations.
Report Facts
Census: 44
Inspection Report
Plan of Correction
Deficiencies: 10
Date: May 30, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during an annual survey inspection. It outlines corrective actions the facility will take to address identified issues.
Findings
The facility identified multiple deficiencies related to resident care plans, notification procedures, maintenance and repair of facility infrastructure, medication administration, dietary services, and equipment availability. Immediate corrective actions were taken, staff were re-educated, and ongoing monitoring plans were established to ensure compliance.
Deficiencies (10)
Failure to notify responsible parties timely of changes in resident condition
Inadequate activity and sensory stimulation plans for residents
Facility maintenance issues including wheelchair repairs, wall damage, carpet cleaning, and shower renovation
Care plans not updated timely for discharge, restorative care, and activity preferences
Fall risk assessments and care plan updates not timely
Delayed procurement and use of adaptive/assistive equipment
Inadequate documentation and administration of fortified food plans and supplements
Medication errors related to PRN and antihypertensive medications and documentation
Kitchen environment issues including cleanliness, food storage, and equipment maintenance
Maintenance and repair of kitchen ceiling, flooring, and nurse station chairs
Report Facts
Deficiencies cited: 10
Monitoring frequency: 5
Monitoring duration: 30
Care Plan meeting dates: May 14, 2012
Care Plan meeting dates: May 15, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Hoover | Administrator | Named as responsible for re-education, monitoring, and reporting to QA and A Committee |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 5
Date: May 4, 2012
Visit Reason
The inspection was conducted as an annual survey to assess compliance with dietary services regulations and overall facility conditions.
Findings
The facility failed to maintain a clean and sanitary dietary department, including issues with food storage, preparation, and service. Observations revealed undated and unlabeled food items, unclean kitchen equipment, and inadequate staffing by a certified dietary manager.
Deficiencies (5)
Presence of an opened undated pitcher of tomato juice and an undated, unlabeled squeeze bottle of salad dressing in the refrigerator.
Steam table pans and scoops stored with visible wetness and dried food debris.
Cookie sheets with brown debris buildup and serving scoops with dried food matter.
Electric meat slicer stored with visible pieces of meat and crumbs; wall area with electric cord covered in dark debris and dust.
Failure to maintain the services of a certified dietary manager to ensure a clean and sanitary dietary department.
Report Facts
Census: 48
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