Inspection Reports for
Richland Care Center, Inc
400 TRI-COUNTY LANE, RICHLAND, MO, 65556-8582
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
16.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
193% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
41% occupied
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 10
Date: Sep 20, 2024
Visit Reason
The document is a Plan of Correction submitted by Richland Care Center Inc following a survey conducted from 09/17/2024 to 09/20/2024. It addresses deficiencies identified during the inspection.
Findings
The facility was found deficient in multiple areas including accounting and records of personal funds, notice and conveyance of personal funds, abuse/neglect policies, infection control, nutrition and food temperature, and water management program. Several residents' personal funds were commingled with facility funds, and policies and procedures were lacking or not properly implemented.
Deficiencies (10)
F568 Accounting and Records of Personal Funds. Facility staff failed to prevent commingling of four residents' personal funds with facility operating funds. The facility did not provide a policy for accounting records.
F569 Notice and Conveyance of Personal Funds. Facility staff failed to provide refunds of personal funds to discharged residents within the required 30 days. The facility did not provide a policy for accounting records.
F607 Develop/Implement Abuse/Neglect Policies. Facility staff failed to complete pre-employment screenings including Criminal Background Check and Family Care Safety Registry verification for three employees.
F688 Increase/Prevent Decrease in ROM/Mobility. Facility must ensure residents with limited range of motion receive appropriate treatment and services to prevent further decrease in mobility.
F804 Nutritive Value/Appearance/Palatability/Preferred Temperature. Facility staff failed to maintain hot food items at 120°F or higher upon service to residents. Residents reported food served cold affected their enjoyment.
F880 Infection Prevention & Control. Facility failed to establish and maintain an infection prevention and control program including annual review and water management to prevent Legionnaire's Disease.
A4032 Personnel Records/Retention. Facility failed to maintain complete personnel records including background checks and training documentation for employees.
A4086 Infection Control/Communicable Disease. Facility failed to report communicable diseases within seven days and maintain infection control policies.
A7036 Food Temperature. Facility failed to serve food at required temperatures of at least 120°F or below 45°F.
A8044 Resident Funds-Itemized Bill. Facility failed to provide an itemized bill for goods and services within 30 days after discharge or death of a resident.
Report Facts
Facility census: 35
Residents sampled: 15
Residents with commingled funds: 4
Employees sampled: 10
Employees failed screening: 3
Inspection Report
Plan of Correction
Census: 35
Capacity: 86
Deficiencies: 21
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as a Life Safety Code survey with multiple deficiencies identified, requiring a plan of correction to address emergency preparedness, fire safety, and other regulatory compliance issues.
Findings
The facility failed to maintain an emergency preparedness plan including tracking on-duty staff during emergencies and failed to conduct required functional testing and maintenance of emergency lighting, fire alarm systems, fire doors, and smoke barriers. Multiple fire safety violations were noted including unsealed holes in fire barriers, unlocked fire alarm panels, and inadequate fire drills.
Deficiencies (21)
E018 Emergency preparedness policies and procedures were not maintained to track location of on-duty staff during emergencies, risking delayed response and affecting all occupants.
K291 Emergency lighting equipment was not tested monthly or annually as required, and emergency light in courtyard did not function, risking evacuation delays.
K321 Hazardous areas were not properly secured with self-closing doors, and rooms used for storage of combustible materials did not have doors that self-closed or latched.
K345 Fire alarm system was not inspected, tested, or maintained properly; fire alarm control panel was unlocked and records of monthly testing were incomplete.
K353 Sprinkler system inspections and maintenance were incomplete; weekly and monthly inspections were missing documentation.
K372 Smoke barriers had unsealed holes and openings, compromising fire containment between zones and risking occupant safety.
K374 Fire-rated doors in smoke barriers did not self-close or latch properly, and multiple holes were found in double egress barrier doors.
K712 Fire drills were not conducted quarterly on each shift as required, and simulated drills with local fire department participation were not done annually.
K761 Fire/smoke door inspections and maintenance were incomplete; doors did not self-close or latch, and records of inspections were missing.
K918 Electrical systems including emergency power generator and essential electrical system were not inspected or maintained as required, risking power failure.
A1023 Dietary office was relocated without proper planning and was not located near the kitchen, impacting food service operations.
A2008 Hazardous areas were not separated by fire-resistant construction and doors were not self-closing, risking fire spread.
A2019 Fire alarm system was not tested and maintained monthly as required, and control panel was unlocked.
A2022 Fire alarm system was not activated monthly as required, risking failure to detect emergencies.
A2034 Sprinkler system was not inspected, tested, or maintained according to requirements.
A2050 Emergency lighting was not tested monthly or annually as required, risking inadequate illumination during emergencies.
A2054 Smoke section walls and doors were not properly maintained; doors did not self-close and fire-rated walls had unsealed holes.
A2058 Fire drills and emergency preparedness plans were incomplete; fire drills were not conducted quarterly on all shifts and simulated drills were missing.
A2061 Fire drill requirements for evacuation and participation of emergency services were not met, risking ineffective emergency response.
A3030 Electrical wiring and equipment were not maintained according to NFPA standards, risking electrical hazards.
A6005 Toxic materials were not stored properly in locked cabinets, making them accessible to residents and creating safety hazards.
Report Facts
Facility census: 35
Total capacity: 86
Deficiencies cited: 21
Inspection Report
Routine
Census: 35
Deficiencies: 5
Date: Sep 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident personal funds management, refund of personal funds upon discharge, pre-employment screenings, food safety and temperature control, and infection prevention and control programs.
Findings
The facility was found deficient in properly managing residents' personal funds, timely refunding discharged residents' funds, completing required pre-employment screenings for staff, maintaining safe food temperatures during service, and implementing a comprehensive water management program to prevent Legionnaire's Disease. The facility census was 35 at the time of inspection.
Deficiencies (5)
Failed to prevent commingling of four current residents' personal funds with facility operating funds and lacked a policy for accounting records.
Failed to provide refunds of personal funds to nine discharged residents within the required 30 days and lacked a policy for accounting records.
Failed to complete pre-employment screenings (Criminal Background Check, Employee Disqualification List verification, Family Care Safety Registry) for three employees.
Failed to ensure prepared hot food items were served at safe and appetizing temperatures; food served to residents in rooms was below required temperature standards.
Failed to develop and implement policies and procedures for inspection, testing, and maintenance of facility water systems to inhibit growth of waterborne pathogens including Legionella.
Report Facts
Facility census: 35
Resident credit balances: 446
Resident credit balances: 988
Resident credit balances: 2971.92
Resident credit balances: 18
Resident credit balances: 2020
Resident credit balances: 226
Resident credit balances: 1323
Resident credit balances: 466.38
Resident credit balances: 452
Resident credit balances: 452
Resident credit balances: 353
Resident credit balances: 7173
Resident credit balances: 1932
Number of employees sampled: 10
Number of employees missing screenings: 3
Food temperature: 105
Food temperature: 114
Food temperature: 92
Food temperature: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Dietary Manager | Assistant DM | Responsible for completing pre-employment screenings; stated screenings were not completed for sampled staff. |
| Maintenance Director | Maintenance Director | Responsible for water management program; unable to provide complete documentation. |
| Administrator | Administrator | Started 08/02/24; responsible for reviewing Account Receivable reports and water management program; unaware of some deficiencies. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Dec 7, 2023
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a sexual abuse allegation towards one resident.
Complaint Details
The complaint investigation was substantiated as the facility failed to report and investigate an allegation of sexual abuse towards one resident within required timeframes.
Findings
The facility failed to report an allegation of sexual abuse within the required two-hour timeframe and failed to investigate the allegation thoroughly. Interviews and record reviews showed staff and administration did not follow proper reporting and investigation procedures.
Deficiencies (4)
F609 Reporting of Alleged Violations: Facility staff failed to report an allegation of sexual abuse towards one resident within the two-hour required timeframe.
F610 Investigate/Prevent/Correct Alleged Violation: Facility staff failed to investigate an allegation of rape for one resident thoroughly.
A8023 Develop/Implement A/N Policies: Facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse as evidenced by F610 findings.
A8025 Report A/N to DHSS/DMH When Needed: Facility failed to immediately report suspected abuse or neglect to the department as evidenced by F609 findings.
Report Facts
Facility census: 33
Plan of correction completion date: Jan 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gachelle Harris | RN, LNHA | Laboratory Director/Provider/Supplier Representative who signed the report |
| Director of Nursing | Named in interviews related to the failure to report and investigate abuse allegations | |
| Certified Nursing Assistant A | Interviewed regarding the abuse allegation and reporting | |
| Administrator | Interviewed regarding reporting procedures and investigation |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report and investigate an allegation of sexual abuse towards one resident (Resident #1).
Complaint Details
The complaint involved an allegation of sexual abuse (rape) towards Resident #1. The allegation was not reported within the required two-hour timeframe, and no investigation was conducted. The Director of Nursing believed the resident's statements were hallucinations due to medication. The administrator was not initially aware of the allegation but later acknowledged the failure to report and investigate properly.
Findings
The facility staff failed to report the sexual abuse allegation to the Department of Health and Senior Services within the required two-hour timeframe and did not investigate the allegation properly. The Director of Nursing assumed the resident's statements were hallucinations related to medication and did not initiate an investigation.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to investigate an allegation of rape for one resident.
Report Facts
Facility census: 33
Resident MDS assessment date: Nov 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant A | Certified Nursing Assistant | Reported the allegation of rape by Resident #1 and stated the Director of Nursing was aware. |
| Director of Nursing | Director of Nursing | Was aware of the allegation but did not investigate, attributing the resident's statements to hallucinations from medication. |
| Administrator | Administrator | Initially unaware of the abuse allegation; later acknowledged failure to be notified and start investigation within required timeframe. |
Inspection Report
Life Safety
Census: 29
Capacity: 86
Deficiencies: 21
Date: May 24, 2023
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with emergency power systems, fire safety equipment, and related safety regulations.
Findings
The facility failed to meet several Life Safety Code requirements including incomplete emergency power system policies, inadequate fire alarm system testing and documentation, missing grease drip pans in the kitchen range hood, and deficiencies in fire door maintenance and sprinkler system upkeep. These failures had the potential to affect all facility occupants.
Deficiencies (21)
E041 Emergency power systems: The facility failed to ensure the emergency preparedness plan included complete policies and procedures for emergency power system operation during outages.
K324 Cooking Facilities: Facility staff failed to maintain the kitchen range hood with a grease drip pan, increasing fire risk in one smoke zone.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to ensure 100% inspection and testing of the fire alarm system and maintain documentation of inspections.
K346 Fire Alarm System - Out of Service: The facility lacked a complete policy for procedures when the fire alarm system is out of service for more than four hours.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain sprinklers free of corrosion, foreign materials, and obstruction, and failed to ensure sprinkler escutcheon plates were properly installed.
K354 Sprinkler System - Out of Service: The facility failed to ensure a policy and procedures were in place for sprinkler systems out of service for more than four hours.
K374 Smoke Barrier Doors: Facility staff failed to maintain fire and smoke doors, including ensuring doors were self-closing and properly sealed.
K511 Utilities - Gas and Electric: Facility staff failed to ensure electrical panels were locked, protected wire splices, and maintain electrical system inspection and maintenance.
K712 Fire Drills: Facility staff failed to conduct fire drills at required intervals and document simulated conditions.
K741 Smoking Regulations: Facility staff failed to ensure proper disposal of cigarette waste in designated smoking areas, risking fire hazards.
K914 Electrical Systems - Maintenance and Testing: Facility staff failed to maintain electrical receptacles and document retention force testing.
A1132 Night-lights-Required Locations: Facility staff failed to provide night-lights in nine resident rooms and two common shower rooms.
A2010 Oxygen Storage: Facility staff failed to secure oxygen tanks properly and maintain combustible materials away from oxygen storage areas.
A2016 Fire Extinguishers UL/FM, Monthly Check: Facility staff failed to maintain portable fire extinguishers in accordance with NFPA 10 standards.
A2034 Sprinkler System-Test/Maintain: Facility staff failed to maintain and test sprinkler systems per NFPA requirements.
A2054 Smoke Section Walls/Doors: Facility staff failed to maintain smoke barrier doors closed and self-closing as required.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Facility staff failed to ensure proper disposal of cigarette waste in designated smoking areas.
A2058 Fire Drill/Emergency Preparedness - Plans: Facility staff failed to maintain a written plan for fire drills and emergency preparedness.
A2061 Fire Drill Requirements, Evacuation: Facility staff failed to conduct required fire drills and simulated resident evacuations annually.
A3030 Electrical Wiring & Equipment Maintained: Facility staff failed to maintain electrical wiring and equipment in accordance with NFPA 70 standards.
A3031 Electrical System-Test/Certify per Code: Facility staff failed to obtain required certification of the electrical system by a qualified electrician every two years.
Report Facts
Facility census: 29
Facility capacity: 86
Number of resident rooms missing night-lights: 9
Number of common shower rooms missing night-lights: 2
Inspection Report
Routine
Census: 29
Deficiencies: 3
Date: May 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards including posting of abuse hotline information, food safety and storage practices, infection prevention and control, and proper use of contact precautions.
Findings
The facility failed to post the required Adult Abuse and Neglect Hotline information in accessible locations, improperly stored and handled food items with multiple sanitation violations, failed to use proper infection control procedures including perineal care and contact precautions for C-diff residents, and did not post required COVID-19 infection prevention guidance at facility entrances.
Deficiencies (3)
Failed to post the required telephone number for the Adult Abuse and Neglect Hotline in accessible locations for residents and visitors.
Failed to store food properly to prevent contamination and out-dated use, failed to wear hair restraints, failed to perform hand hygiene, and failed to keep kitchen waste containers covered.
Failed to use appropriate infection control procedures including improper perineal care wiping technique and failure to maintain transmission-based precautions for a resident with C-diff infection.
Report Facts
Census: 29
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician G | Certified Medication Technician | Interviewed regarding posting of Adult Abuse and Neglect Hotline number |
| Licensed Practical Nurse H | Licensed Practical Nurse | Interviewed regarding posting of Adult Abuse and Neglect Hotline number and contact precautions |
| Nurse Aide F | Nurse Aide | Interviewed regarding posting of Adult Abuse and Neglect Hotline number and infection control |
| Director of Nursing | Director of Nursing | Interviewed regarding posting of Adult Abuse and Neglect Hotline number, infection control expectations, and COVID-19 posting requirements |
| Activities Director | Activities Director | Interviewed regarding posting of Adult Abuse and Neglect Hotline number |
| Restorative Aide | Restorative Aide | Interviewed regarding posting of Adult Abuse and Neglect Hotline number |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, hair restraint use, and hand hygiene |
| Administrator | Administrator | Interviewed regarding food safety policies, hair restraint use, hand hygiene monitoring, and COVID-19 posting requirements |
| Dietary Aide M | Dietary Aide | Observed and interviewed regarding hair restraint use and hand hygiene |
| Dietary Aide N | Dietary Aide | Observed and interviewed regarding hand hygiene and hair restraint use |
| Certified Nurse Aide A | Certified Nurse Aide | Observed providing perineal care improperly |
| Certified Nurse Aide B | Certified Nurse Aide | Observed providing perineal care improperly |
| Certified Nurse Aide C | Certified Nurse Aide | Observed providing perineal care improperly and failing to use PPE for C-diff resident |
| Nurse Aide K | Nurse Aide | Interviewed regarding contact precautions for C-diff resident |
| Licensed Practical Nurse I | Licensed Practical Nurse | Observed entering C-diff resident room without appropriate PPE |
| Infection Preventionist | Infection Preventionist | Interviewed regarding COVID-19 posting requirements |
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 9
Date: May 24, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations including required postings, food safety, infection control, and other health and safety standards at Richland Care Center Inc.
Findings
The facility failed to post required telephone numbers for the Adult Abuse and Neglect Hotline in accessible locations. Food safety violations included improper storage, uncovered waste containers, and failure to use hair restraints. Infection control deficiencies involved inadequate hand hygiene, failure to maintain transmission-based precautions, and lack of proper signage for COVID-19 guidance.
Deficiencies (9)
F575 Required Postings: The facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in accessible locations for residents, visitors, or staff.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility staff failed to store food to prevent contamination and out-dated use, failed to wear hair restraints, and failed to perform hand hygiene to prevent cross-contamination.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention program, failed to use appropriate infection control procedures, and failed to post COVID-19 guidance signage.
A6031 Kitchen Waste Containers Covered: Waste containers in food-preparation and utensil-washing areas were not kept covered when not in use.
A7002 Wash Hands/Arms & Clean Fingernails: Employees failed to thoroughly wash hands and keep fingernails clean as required.
A7003 Clean Clothing, Hair Restraints: Employees failed to wear clean clothing and effective hair restraints to prevent contamination of food or food-contact surfaces.
A7015 Food-Protected, Temp, Need to Contact DHSS: Food was not properly protected from contamination and not stored at required temperatures.
A4086 Infection Control/Communicable Disease: The facility failed to report communicable diseases timely and maintain infection control measures.
A8020 Exercise Rights/Voice Grievances: Residents were not adequately informed or assisted in exercising their rights and voicing grievances.
Report Facts
Facility census: 29
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Feb 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation and exploitation of a resident's property by a Certified Medication Technician (CMT).
Complaint Details
The complaint was substantiated as the facility failed to prevent misappropriation of a resident's property by a staff member. The staff member was terminated and the facility implemented corrective actions.
Findings
The facility failed to prevent misappropriation of a resident's bank card by a staff member who used it without authorization for multiple purchases. The staff member was suspended and terminated, and the facility took corrective actions including staff education and notifying responsible parties.
Deficiencies (1)
CFR 483.12: The resident was not free from misappropriation as a Certified Medication Technician used the resident's bank card without authorization for purchases. The facility failed to prevent this misappropriation.
Report Facts
Facility census: 27
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Dec 8, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding abuse and neglect involving Resident #1 and Resident #2.
Complaint Details
The complaint investigation substantiated that Resident #2 grabbed Resident #1's chest and attempted to push Resident #1 into his/her room and close the door. Resident #2 was sent for psychological evaluation and placed on continuous 15-minute checks until discharge.
Findings
The facility failed to keep one resident free from sexual abuse as Resident #2 touched Resident #1's chest. The investigation confirmed incidents of inappropriate behaviors and inadequate supervision leading to harm and distress.
Deficiencies (2)
F 600 Freedom from Abuse and Neglect: The facility failed to keep one resident free from sexual abuse when Resident #2 touched Resident #1's chest. The facility did not meet the requirement to prevent abuse, neglect, and mistreatment.
A4074 Protective Oversight, Voluntary Leave: The facility did not meet the requirement for protective oversight and supervision for residents on voluntary leave, as referenced in F600.
Report Facts
Facility census: 31
Inspection Report
Plan of Correction
Census: 26
Deficiencies: 1
Date: May 26, 2022
Visit Reason
The inspection was conducted to assess compliance with COVID-19 vaccination requirements for facility staff.
Findings
The facility failed to develop and implement policies and procedures to ensure all staff were fully vaccinated or had approved exemptions. One Nursing Aide was not vaccinated and lacked documentation for exemption or delay.
Deficiencies (1)
F 888 COVID-19 Vaccination of Facility Staff. The facility did not ensure all staff were fully vaccinated or had approved exemptions as required by policy. One Nursing Aide was not vaccinated and had no exemption documentation.
Report Facts
Facility census: 26
Employee vaccination rate: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nursing Aide | Named in vaccination deficiency as unvaccinated staff without exemption documentation |
| NA A | Nursing Aide | Mentioned as new hire and subject of vaccination documentation review |
Inspection Report
Routine
Deficiencies: 0
Date: Jan 14, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Date: Oct 8, 2020
Visit Reason
The inspection was conducted due to complaints regarding medication error rates exceeding 5% and failure to implement proper infection prevention and control practices, including improper storage of oxygen tubing and failure to maintain transmission-based precautions.
Complaint Details
The visit was complaint-related due to concerns about medication error rates and infection control practices. The complaint was substantiated as deficiencies were found in medication administration and infection prevention protocols.
Findings
The facility staff failed to ensure medication error rates were below 5%, with two medication errors out of 25 opportunities (7.69%). Additionally, staff failed to properly store oxygen tubing and nebulizer masks for multiple residents and did not maintain proper transmission-based precautions, including leaving doors open for residents on high-risk COVID-19 monitoring.
Deficiencies (3)
Medication error rate exceeded 5%, with staff failing to hold the insulin needle in the skin for 5 seconds as per policy.
Failure to store oxygen tubing and nebulizer masks properly to avoid contamination for four residents.
Failure to maintain proper transmission-based precautions for two residents, including leaving doors open despite high-risk status.
Report Facts
Medication error rate: 7.69
Medication errors: 2
Opportunities for error: 25
Census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in medication error findings and interview regarding insulin administration |
| Director of Nursing | Director of Nursing | Provided interview statements regarding insulin administration and infection control policies |
| Certified Nurse Assistant D | Certified Nurse Assistant | Observed improperly storing oxygen tubing |
| Certified Nurse Assistant F | Certified Nurse Assistant | Interviewed regarding residents on high level monitoring and door status |
| Administrator | Administrator | Interviewed regarding lack of oxygen storage policy |
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 4
Date: Oct 8, 2020
Visit Reason
The inspection was conducted to assess compliance with medication administration and infection control regulations, including review of insulin administration practices and infection prevention protocols.
Findings
The facility failed to maintain a medication error rate below 5%, with two medication errors affecting two residents. The infection prevention and control program was found deficient, including improper storage of oxygen tubing and failure to maintain transmission-based precautions for certain residents.
Deficiencies (4)
F759 Medication Errors. The facility failed to ensure medication error rates were less than 5%, with two medication errors resulting in a 7.69% error rate affecting two residents.
F880 Infection Prevention & Control. The facility failed to establish and maintain an infection prevention program, including improper storage of oxygen tubing and failure to maintain transmission-based precautions for residents.
A4059 Medication Errors/Adverse Reactions. All medication errors and adverse reactions were not reported immediately to the nursing supervisor and physician as required.
A4085 Infection Control/Communicable Disease. The facility failed to use acceptable infection control procedures to prevent the spread of infection and report communicable diseases as required.
Report Facts
Medication error rate: 7.69
Facility census: 32
Medication errors: 2
Units of insulin administered: 9
Units of insulin administered: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Kay Smith | Administrator | Signed the plan of correction and final report. |
| Director of Nursing | Interviewed regarding insulin administration and infection control policies. | |
| LPN A | Licensed Practical Nurse | Observed administering insulin and interviewed about insulin administration technique. |
| CNA F | Certified Nurse Assistant | Interviewed about resident monitoring and door policies. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Oct 8, 2020
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with emergency preparedness and fire safety regulations.
Findings
No deficiencies were found related to emergency preparedness or life safety code compliance. No state licensure deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cleo Kay Smith | Administrator | Signed the inspection report and plan of correction. |
Inspection Report
Routine
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 5
Date: May 16, 2019
Visit Reason
The inspection was the annual survey of Richland Care Center to assess compliance with federal regulations including nurse staffing, psychotropic drug use, menu and nutritional adequacy, food safety, infection control, and water management.
Findings
The facility failed to post accurate nurse staffing information including census and hours worked. Deficiencies were found related to psychotropic drug use without proper diagnoses and gradual dose reductions, failure to prepare and serve food according to physician orders and menus, inadequate handwashing and food safety practices, and incomplete infection prevention and water management policies.
Deficiencies (5)
F732 Nurse staffing information was not posted accurately, missing actual hours worked and census data for direct care staff on multiple days.
F758 Psychotropic drug use deficiencies included lack of appropriate diagnoses for residents, failure to perform gradual dose reductions, and incomplete documentation for PRN orders.
F803 Menus and nutritional adequacy were deficient as staff failed to prepare and serve food items according to physician orders and menus, including pureed diets and portion sizes.
F812 Food procurement, storage, preparation, and serving were deficient due to failure to wash hands properly and maintain sanitary conditions during food handling.
F880 Infection prevention and control program was deficient due to failure to develop and implement policies for water management, infection control procedures, and cleaning of glucometers.
Report Facts
Facility census: 38
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Kay Smith | Administrator | Named in relation to nurse staffing posting and plan of correction |
| Licensed Practical Nurse B | Interviewed regarding daily staff posting and glucometer cleaning | |
| Director of Nursing | Interviewed regarding nurse staffing posting and medication review responsibilities | |
| Cook C | Observed and interviewed regarding food preparation and menu adherence | |
| Dietary Manager | Interviewed regarding food preparation and handwashing policies |
Inspection Report
Life Safety
Census: 38
Capacity: 86
Deficiencies: 2
Date: May 16, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, focusing on delayed-egress locking systems on exit doors.
Findings
The facility failed to maintain six exit doors equipped with delayed-egress locking systems that did not automatically release upon fire alarm activation. This failure has the potential to delay evacuation and affect all facility occupants.
Deficiencies (2)
K222: Facility staff failed to ensure delayed-egress locking systems on six exit doors automatically released upon fire alarm activation, potentially delaying evacuation. The facility census was 38 with a capacity of 86.
A2041: Door locks did not meet NFPA 101 requirements for being operable from the inside by a simple device or knob. Only one lock permitted per door, violating Class II regulations.
Report Facts
Facility census: 38
Total capacity: 86
Number of exit doors with delayed-egress locking: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clint Ray Smith | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 4
Date: May 1, 2018
Visit Reason
The inspection was conducted in response to allegations of sexual abuse against a Certified Nursing Assistant (CNA) reported by a resident's family member.
Complaint Details
The complaint investigation was substantiated. The facility failed to notify DHSS within the required two-hour timeframe of an allegation of sexual abuse by a CNA against a resident. Interviews revealed staff and administration misunderstood or failed to follow reporting requirements.
Findings
The facility failed to develop and implement adequate abuse and neglect policies, including timely reporting requirements. Staff failed to notify the Department of Health and Senior Services (DHSS) of an allegation of sexual abuse within the required two-hour timeframe.
Deficiencies (4)
F607: The facility did not develop a written policy regarding notifying DHSS of abuse allegations within the required two-hour timeframe. Staff failed to include the required time frame for notification in their policies.
F609: The facility failed to report an allegation of employee-to-resident sexual abuse within the required two-hour timeframe to DHSS. Staff did not notify DHSS of the allegation within the required time.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, including reporting requirements to the department and Department of Mental Health.
A8025: The facility failed to immediately report or cause to report to DHSS/DMH any suspected abuse or neglect of a resident by an employee or administrator.
Report Facts
Facility census: 37
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 6
Date: Apr 13, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for Richland Care Center, Inc.
Findings
The facility was found deficient in multiple areas including comprehensive assessments after significant change, care plan timing and revision, restorative nursing, nutrition/hydration status maintenance, and dining and resident activities. Staff failed to complete required assessments and care plan updates for several residents, and care plans lacked necessary details and interventions.
Deficiencies (6)
F637 Comprehensive Assessment After Significant Change: Facility failed to complete comprehensive significant change Minimum Data Set (MDS) assessments for five residents out of 12 sampled. Staff did not complete significant change MDS as directed by the Resident Assessment Instrument (RAI) manual.
F657 Care Plan Timing and Revision: Facility staff failed to ensure care plans were reviewed, updated, and revised for five sampled residents. The facility lacked a policy for care plan updates and revisions.
F688 Restorative Nursing: Facility failed to provide range of motion for limited mobility residents and did not implement restorative nursing programs or splint schedules as needed. Documentation was incomplete and did not include refusals or restorative care charting.
F692 Nutrition/Hydration Status Maintenance: Facility failed to ensure physician's nutritional orders were followed and that residents received appropriate diets and hydration. Staff did not provide thickened liquids as ordered and failed to monitor significant weight loss.
F803 Menus Meet Resident Needs/Preparation and Follow-up: Facility failed to serve food items in accordance with physician orders and did not provide adequate nutritional adequacy. Staff did not offer all foods on the menu and failed to provide desserts as directed.
F920 Requirements for Dining and Activity Rooms: Facility failed to provide dining tables at comfortable heights for residents and adequate space to accommodate all activities. Observations showed residents had difficulty reaching food and drinks at tables.
Report Facts
Resident census: 39
Sampled residents: 12
Deficiencies cited: 6
Inspection Report
Life Safety
Census: 39
Capacity: 86
Deficiencies: 10
Date: Apr 13, 2018
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness, life safety code, and fire safety regulations at Richland Care Center.
Findings
The facility failed to develop adequate emergency preparedness policies for volunteers and alternate care sites, did not maintain a written emergency preparedness training program, and failed to meet several life safety code requirements including fire drills, range hood maintenance, and gas equipment training.
Deficiencies (10)
E024 Policies and procedures. The facility failed to develop policies for the use of volunteers or other staffing strategies in emergencies. The facility census was 39 with a capacity of 86.
E026 Roles Under a Waiver Declared by Secretary. The facility failed to develop policies regarding care and treatment at alternate care sites under an 1135 waiver. The facility census was 39 with a capacity of 86.
E036 EP Training and Testing. The facility failed to develop a written emergency preparedness training and testing program. The facility census was 39 with a capacity of 86.
K324 Cooking Facilities. The facility failed to maintain the kitchen range hood in accordance with NFPA 96, affecting one smoke zone including the main dining room. The facility census was 39 with a capacity of 86.
K712 Fire Drills. The facility failed to conduct and document fire drills quarterly on each shift from April 2017 through March 2018. The facility census was 39 with a capacity of 86.
K926 Gas Equipment - Qualifications and Training. The facility failed to provide continuing education on safety guidelines and usage requirements for medical gases and cylinders. The facility census was 39 with a capacity of 86.
A2017 Range Hood Certification. The facility failed to provide certification of the cooking range hood and extinguishing system at least twice annually as required by NFPA 96.
A2058 Fire Drill/Emergency Preparedness - Plans. The facility failed to have a written plan to meet potential emergencies or disasters and to request consultation and assistance annually from a local fire unit.
A2061 Fire Drill Requirements, Evacuation. The facility failed to conduct at least four unannounced fire drills per shift annually, including simulated resident evacuation involving local emergency services.
A4022 Employee Orientation/Continuing Education. The facility failed to develop and offer an in-service orientation and continuing education program for all personnel including licensed nurses and other professionals.
Report Facts
Facility census: 39
Total capacity: 86
Number of fire drills: 4
Number of fire drills conducted: 0
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