Mission at Richfield Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mission at Richfield Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 7, 2024

  Based on interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 18 sampled residents, a resident that required extensive assistance of two or more persons for bed mobility and toilet use had a brief change performed by one Certified Nursing Assistant (CNA), rolled out of the bed, and fractured their right hip. […]

• No harm, potential for more than minimal, patternF584Jun 11, 2026

  Based on observation, interview, and record review it was determined, for 3 out of 36 sampled residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, residents' room doors slammed closed, multiple walls in resident's rooms were in disrepair, and resident's personal belongings were lost with no process put in place to locate or replace them. Resident identifiers: 1, 2 and 4.Findings included:DOORS:On 6/8/26 at 10:15 AM, an interview was conducted with resident 1 who stated the staff always slammed his door closed, even when he asked them not to. […]

• No harm, potential for more than minimal, isolatedF605Jun 11, 2026

  Based on interview and record review it was determined the facility did not ensure that each resident who was given a psychotropic drug had an adequate indication for use of the medication; that psychotropic drugs received a gradual dose reduction and behavioral interventions, unless clinically contraindicated; as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the practitioner documented a clinical rationale to extend beyond 14 days with a duration of use for the order. Specifically, for 1 out of 36 sampled residents, the facility did not document a practitioner rationale for continuing a PRN psychotropic medication past 14 days. […]

• No harm, potential for more than minimal, isolatedF627Jun 11, 2026

  Based on record review and interview, it was determined that for 1 out of 36 sampled residents, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions; the facility's discharge planning process must include regular re-evaluation of residents to identify changes that required modification of the discharge plan; the discharge plan must be updated, as needed, to reflect these changes; involve the interdisciplinary team (IDT) in the ongoing process of developing the discharge plan; involve the resident and resident representative in the development… […]

• No harm, potential for more than minimal, isolatedF656Jun 11, 2026

  Based on record review and interview, it was determined that, for 1 out of 36 sampled residents, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, one resident's care plan was not updated to include revised interventions after he removed his wander guard for a fourth time and eloped. […]