New Richland Care Center

In the surveyor’s words

From the most serious findings on record at New Richland Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Nov 18, 2024

  Based on observation, interview and document review, the facility failed to have a system in place for pressure ulcer prevention and management that included comprehensive assessments, monitoring, physician involvement, and individualized wound treatments and interventions for 4 of 4 residents (R1, R2, R3, R4) who had ongoing, recurrent, and deteriorating pressure wounds. As a result of the facility's systemic failure, R1 developed a stage 4 pressure ulcer that resulted in sepsis, osteomyelitis, and death resulting in immediate jeopardy. The IJ began on [DATE], when the facility failed to monitor, assess, and immediately notify the physician when R1's wound had increased drainage and pain which resulted in delay of care for four days followed by hospitalization and death. […]

• Immediate jeopardy, isolatedF600Apr 25, 2022

  Based on observation, interview and document review, the facility failed to protect 1 of 1 residents (R1) from sexual abuse when an incident of sexual abuse was observed, was not reported to the administrator, and led to a subsequent second observation of sexual abuse involving nursing assistant (NA)-A. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on 1/25/22, at 6:30 p.m., when culinary aide (CA)-A observed R1 touching NA-A breast while NA-A stood above R1 in his wheelchair in resident room. CA-A reported this to her supervisor, culinary director (CD)-A but was told to wait to report to the facility social worker (SW)-A in the morning. NA-A continue to work her shift. That same day, NA-G observed another incident of alleged sexual abuse at 10:45 p.m. […]

• No harm, potential for more than minimal, widespreadF867Feb 19, 2025

  Based on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan to guide facility efforts in assuring care and services were maintained at acceptable levels of performance and continually improved. This had the potential to affect all 38 residents residing in the facility. Findings include: During entrance conference on 2/18/25 at 11:25 a.m., with the administrator and director of nursing (DON), the facility QAPI plan was requested. During an interview on 2/19/25 at 3:00 p.m., the QAPI plan was requested again. The administrator stated the facility did not have a written QAPI plan. […]

• No harm, potential for more than minimal, widespreadF880Feb 19, 2025

  Based on observation, interview, and record review the facility failed to ensure Centers for Disease Control (CDC) guidance was followed for fit testing for N95 filtering facepiece respirators prior to use and annually. Findings include: During observation on 2/18/25 at 11:49 a.m., the facility had signs posted on the front entrance door indicating mask use required due to respiratory outbreak. During observation and interview on 2/18/25 at 12:35 p.m., housekeeping assistant (H-A) was observed putting an N95 mask over a regular surgical mask prior to entering a resident room requiring N95 use due to Covid isolation. […]

• No harm, potential for more than minimal, widespreadF865Nov 18, 2024

  Based on observation, interview, and document review, the facility failed to maintain a Quality Assurance Performance Improvement/Quality Assurance Activity (QAPI/QAA) that was effective in identifying, assessing, performing, developing, and implementing appropriate plans of action related to impaired skin integrity and/or pressure injuries. This deficient practice had the potential to affect all 34 residents currently residing in the facility. Findings include On 11/15/24, the director of nursing (DON) provided the facility's Quality Assurance Performance Improvement/Quality Assurance Activity (QAPI/QAA) project documents and plans. […]