Inspection Reports for
Richwood Nursing &Amp; Rehab
1012 RICHWOOD WAY, LA GRANGE, KY, 40031
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
28% occupied
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 7
Date: Mar 13, 2025
Visit Reason
The inspection was conducted to investigate complaints related to resident care, notification of transfers, care plan implementation, assistance with activities of daily living, fall prevention, respiratory care, and staff performance evaluations at Richwood Nursing & Rehab.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate resident care, failure to notify the Ombudsman of hospital transfers, incomplete care plans, insufficient assistance with ADLs, fall prevention failures, improper respiratory equipment handling, and lack of staff performance evaluations. The complaints were substantiated with findings of minimal harm affecting a few or some residents.
Findings
The facility failed to provide a safe, homelike environment, timely notification of resident transfers to the Ombudsman, implementation of comprehensive care plans, assistance with activities of daily living, fall prevention interventions, proper respiratory care, and annual performance evaluations for CNAs. Multiple residents experienced care deficiencies including lack of assistance with eating and incontinence care, improper storage of equipment, and missing staff education documentation.
Deficiencies (7)
F0584: The facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 33 sampled residents by storing multiple wheelchairs and equipment in the resident's room.
F0623: The facility failed to send timely notification of resident transfers to the Office of the State Long-Term Care Ombudsman for 2 of 33 sampled residents.
F0656: The facility failed to implement comprehensive person-centered care plans for 2 of 33 sampled residents, resulting in lack of staff education and failure to ensure interventions such as dycem placement in wheelchair.
F0677: The facility failed to provide sufficient and timely assistance with activities of daily living for 2 of 33 sampled residents, including incontinence care and eating assistance.
F0689: The facility failed to ensure residents were free from accident hazards by not consistently ensuring fall prevention interventions such as dycem placement in wheelchair for 1 of 33 sampled residents.
F0695: The facility failed to provide safe and appropriate respiratory care by not storing nasal cannulas in bags when not in use for 1 resident.
F0730: The facility failed to complete annual performance evaluations for 4 of 4 CNAs reviewed within the required 12-month period.
Report Facts
Residents sampled: 33
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
CNAs reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Responsible for notifying Ombudsman of resident transfers; interviewed multiple times regarding notification failures |
| Director of Nursing | Director of Nursing | Provided statements on care plan expectations, fall prevention, and staff performance evaluations |
| Administrator | Administrator | Provided statements on facility policies, staffing, and performance evaluations |
| Infection Preventionist | Infection Preventionist/Quality Assurance | Responsible for staff education and audits related to fall prevention and respiratory care |
| Certified Nursing Assistant 8 | CNA | Provided information on staff rounding and incontinence care expectations |
| Certified Nursing Assistant 10 | CNA | Provided information on staff responsibilities and care plan adherence |
| Certified Nursing Assistant 11 | CNA | Provided information on agency staffing and resident care practices |
| Certified Nursing Assistant 12 | CNA | Provided information on agency staffing and rounding expectations |
| Licensed Practical Nurse 11 | LPN | Provided information on staffing levels and care expectations |
| Licensed Practical Nurse 10 | LPN | Provided information on staffing challenges and resident care |
| Unit Manager 1 | Unit Manager | Provided information on agency staff orientation and care expectations |
| Nurse Practitioner 1 | Nurse Practitioner | Provided observations on agency staff and resident care |
| Minimum Data Set Nurse | MDS Nurse | Provided information on care plan development and importance of adherence |
| Physical Therapy Assistant | PTA | Provided information on resident mobility and fall risk |
Inspection Report
Abbreviated Survey
Census: 107
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
An abbreviated survey was conducted to investigate multiple CMS identification numbers related to Richwood Nursing & Rehab, focusing on deficient practices identified in a prior investigation.
Findings
The facility was found to have a past noncompliance deficiency at a 'G' level severity related to accident hazards and supervision, specifically involving a resident who fell from a transport van resulting in injuries. The facility had corrected the deficient practice prior to this survey. No new deficient practices were cited during this survey.
Deficiencies (1)
Failure to prevent accidents for a resident who fell backwards out of the facility's transport van, resulting in a closed head injury, rib fractures, and cervical spine strain.
Report Facts
Facility Census: 107
Sample Size: 21
Distance of fall: 10.33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Involved in the incident with Resident 19 and described in interviews regarding the fall from the transport van |
| CNA2 | Certified Nursing Assistant | Witnessed the incident and provided statements about the transport van and staff training |
| Director of Nursing | Director of Nursing | Called by CNA1 after the incident and advised to send Resident 19 to the emergency room |
| Administrator | Administrator | Interviewed regarding the incident and root cause analysis |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
The investigation was conducted due to a complaint regarding a resident (R19) who fell from the back of a transport van when staff released safety restraints before the hydraulic lift was in place, resulting in serious injury and subsequent death.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent a resident's fall from the transport van due to staff error and inadequate policies. The resident sustained serious injuries and later expired. Staff interviews and video review confirmed the incident circumstances.
Findings
The facility failed to prevent accidents by not ensuring proper use of the mechanical lift during resident transport. Staff released safety restraints prematurely, and facility policies did not adequately address safe procedures for van lift use, contributing to the resident's fall and injuries.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. A resident fell approximately 10 feet from a transport van when staff released safety restraints before the hydraulic lift was in place, resulting in actual harm including head injury and fractures.
Report Facts
Residents sampled: 22
Fall distance: 10.33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Named in the finding for releasing safety restraints prematurely and failing to ensure the lift was in place |
| CNA2 | Certified Nursing Assistant | Witnessed the fall and provided information on training and transport procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding incident response and resident's familiarity with transport procedures |
| Administrator | Administrator | Interviewed about incident notification, root cause analysis, and policy deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 26, 2019
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure residents could access their personal funds on weekends.
Complaint Details
The complaint was substantiated. The facility was found to have failed in ensuring weekend access to personal funds for residents #91 and #94.
Findings
The facility failed to provide weekend access to personal funds for two sampled residents. Interviews and record reviews revealed the business office was closed on weekends, the receptionist position was vacant, and staff had inconsistent knowledge about weekend fund access procedures.
Deficiencies (1)
F 0567: The facility failed to honor residents' rights to manage their personal funds by not providing access to funds on weekends as required by policy. Two residents were unable to obtain their personal funds on weekends due to office closure and lack of staff access.
Report Facts
Residents sampled: 24
Residents affected: 2
BIMS score: 15
Time window for weekend fund request: 2
Reasonable wait time for funds: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding weekend fund access and receptionist vacancy | |
| Unit Manager of the A Unit | Interviewed about weekend fund access procedures | |
| Director of Nursing (DON) | Interviewed about residents' access to personal funds and receptionist replacement | |
| Administration Assistant | Interviewed about procedures for residents requesting funds and office hours | |
| Accounts Receivable Coordinator (ARC) | Interviewed about personal fund accounts and weekend fund access | |
| Certified Nursing Assistant (CNA) #2 | Interviewed about residents requesting funds ahead of time and weekend procedures | |
| Administrator | Interviewed about business office hours, receptionist vacancy, and fund access policy |
Inspection Report
Routine
Deficiencies: 4
Date: May 17, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, catheter care, infection prevention, and control practices at Richwood Nursing & Rehab.
Findings
The facility failed to post notice of survey results for residents, did not secure an indwelling urinary catheter for one resident as per policy, and failed to maintain proper infection control practices including uncovered clean resident clothing during transport and improper storage of a resident's nebulization mask.
Deficiencies (4)
F 0577: The facility failed to post a notice of the availability of the most recent survey results in prominent and accessible areas for residents to view.
F 0657: The facility failed to revise the care plan to include interventions securing the indwelling urinary catheter for Resident #7, resulting in the catheter not being secured to reduce friction and movement at the insertion site.
F 0690: The facility failed to ensure appropriate catheter care for Resident #7, as staff did not secure the indwelling urinary catheter to prevent trauma, contrary to facility policy.
F 0880: The facility failed to maintain an effective infection control program; clean resident clothing was transported uncovered exposing it to dust, and Resident #79's nebulization mask was not stored in a sanitary manner within a plastic covering.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 1
In-service staff trained: 8
Physician BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed catheter care and skin assessment for Resident #7 |
| CNA #1 | Certified Nursing Assistant | Provided catheter care for Resident #7 and interviewed regarding catheter securing |
| CNA #4 | Certified Nursing Assistant | Assisted with turning Resident #7 and interviewed regarding catheter securing |
| Director of Nursing | Director of Nursing | Interviewed regarding catheter care and infection control concerns |
| Housekeeper #1 | Housekeeper | Observed transporting clean resident clothing uncovered |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding laundry policy and staff training |
| CNA #5 | Certified Nursing Assistant | Observed in Resident #79's room during infection control observations |
| CNA #3 | Certified Nursing Assistant | Interviewed about Resident #79's nebulizer use and mask storage |
| LPN #7 | Licensed Practical Nurse | Interviewed about Resident #79's breathing treatment and mask storage |
| Unit Manager | Unit Manager | Interviewed about infection control practices for Resident #79's nebulizer mask |
| Administrator | Administrator | Interviewed about infection control program oversight |
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