Inspection Reports for Richmond Center for Rehabilitation and Specialty Healthcare

Failed to ensure that a resident received adequate supervision to prevent elopement during a clinic appointment.

Free of accident hazards/supervision/devices

Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Failure to ensure a resident received adequate supervision and assistance to prevent accidents, resulting in a fall and head laceration.

Resident #166 was not provided with adequate clothing to ensure a dignified existence.

Resident #225 was fed by staff standing over them instead of sitting, compromising dignity.

Facility did not ensure residents' right to communicate with individuals external to the facility on Saturdays due to mail delivery system.

Residents #170, #327, #351, and #334 were not provided with a written summary of their baseline care plan (BCP).

Resident #351 did not have a comprehensive care plan addressing dental needs despite poor dentition and missing teeth.

Resident #335 with sacral pressure ulcer had no dressing observed during wound care, risking infection.

Resident #166 experienced significant weight loss without documented interventions to prevent further loss.

Expired medication (Narcan) was found in the Emergency Medication Box on Unit 4.

Multiple bags of IV antibiotics stored in a refrigerator without a thermometer; an opened, undated vial of insulin was found in medication cart.

Food was stored and served at temperatures above 41°F, including refrigerators malfunctioning and containing items above safe temperature.

Garbage compactor located outside the facility lacked a lid or door, allowing flies to harbor and feed.

Infection prevention and control practices were not maintained for 5 residents, including improper hand hygiene during tracheostomy care, improper PPE use for residents on contact precautions, and failure to sanitize equipment between residents.

Baseline care plan; Develop/implement comprehensive care plan; Dispose garbage and refuse properly; Food procurement, store/prepare/serve-sanitary; Free of accident hazards/supervision/devices; Infection prevention & control; Label/store drugs and biologicals; Nutrition/hydration status maintenance; Pharmacy services/procedures/pharmacist/records; Reporting of alleged violations; Resident rights/exercise of rights; Right to forms of communication w/ privacy; Subsistence needs for staff and patients; Treatment/services to prevent/heal pressure ulcer; Electrical systems - essential electric system; Gas equipment - cylinder and container storage; Means of egress - general; Portable fire extinguishers; Sprinkler system - maintenance and testing; Subdivision of building spaces - smoke barrier

Administration; Free from abuse and neglect; Reporting of alleged violations

Failure to immediately notify a resident's representative of changes to psychotropic medication regimen.

Comprehensive Care Plan related to cognition was not complete with individualized interventions.

Delayed diagnosis and treatment of left clavicle fracture after fall; x-ray not ordered timely.

Residents on oxygen therapy received oxygen at incorrect flow rates.

Medication refrigerator had melting ice causing water leakage; insulin pen stored improperly submerged in water.

Food service issues including late delivery, cold food, missing items, and poor palatability reported by residents.

Improper storage of residents' personal food items with undated, unlabeled, and spoiled food found in pantry refrigerator.

Failure to perform proper hand hygiene during wound care and after resident care by staff.

Failure to provide timely quarterly statements to residents for their personal funds, specifically resident #38.

Medical equipment, including feeding pumps and poles, were observed dirty and not properly sanitized in 2 of 4 units.

Residents #193, 249, and 262 were not afforded the right to participate in the planning of their care as evidenced by interviews and lack of documentation.

Staff failed to implement proper hand hygiene procedures during direct resident contact, specifically a respiratory therapist did not wash hands prior to suctioning resident #72.