Landmark of Richton Park Rehab & NSG CTR

In the surveyor’s words

From the most serious findings on record at Landmark of Richton Park Rehab & NSG CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Mar 31, 2022

  Based on observation, interview and record review, the facility failed to have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to activate 911 emergency services and monitor one vent dependent resident (R17) who was in respiratory distress. Additionally, the facility failed to ensure a ventilator was set up and ready for use at the time of (R17) admission. This failure affected 2 of 4 residents (R6, R17) reviewed for respiratory services. These failures resulted R6 experiencing respiratory distress, the facility staff removing R6's inner/outer cannulas and were unable to correctly replace the cannula back in place for R6. […]

• Immediate jeopardy, isolatedF600Feb 10, 2021

  Based on interviews, and record reviews, the facility neglected to assess a resident found on the floor, next to the bed after an avoidable fall incident. The facility also neglected the resident by walking around the resident leaving the morning medication at the bedside, and documented in the nursing notes that the resident was sleeping on the floor. This affected one of four (R2) residents reviewed for neglect. These neglectful actions resulted in R2 being left on the floor for over 2 hours until morning staff found R2 on the floor. R2 told staff that R2 had fallen the night before attempting transfer to the bed from the wheelchair. […]

• Immediate jeopardy, isolatedF678Feb 10, 2021

  Based on interviews, and record reviews, this facility failed to provide effective basic life support/cardiopulmonary resuscitation for one resident (R1) who required resuscitative care. R1 was found to be non-responsive without a pulse and was only receiving ventilations via [MEDICAL CONDITION] when EMS (emergency medical services) arrived. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE]. The immediate jeopardy was identified on [DATE]. […]

• Actual harm, isolatedF684Feb 18, 2026

  Based on observation, interview and record review, the facility failed to provide a resident with services to avoid emotional distress and anguish by failing to assist a post-op patient with follow-up appointment, failed to ensure that resident was receiving therapy as ordered and failed to ensure that staff assist the resident with activities of daily living (ADL). These failures affected one (R3) of four residents reviewed for quality of care. As a result, R3 developed increased swelling, increased pain and blood clot to his right hip and stated that he feels hopeless since being admitted because he thinks nobody cares about his pain and healing process.Findings include:R3 is a [AGE] year-old male admitted to the facility on [DATE] post open reduction and internal fixation (ORIF… […]

• Actual harm, isolatedF697Feb 18, 2026

  Based on observation interview and record review, the facility failed to manage post-op pain for one resident (R3) by failing to administer pain medications (Oxycodone and Tylenol) as ordered, failed to monitor and document effectiveness of pain relief, and failed to use non-pharmacological interventions as part of the pain control regimen as care planned. This failure affected one (R3) of four residents reviewed for pain management. These failures contributed to R3 suffering psychological harm and feeling a sense of hopeless because no one cared about his pain or healing and pain rated 10 on a scale of 1-10.Findings include: On 2/1/2026 11:00AM, R3 was observed in his room, awake and alert, said that facility is not controlling his pain and not getting his pain medication orders straight,… […]