Richland Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Richland Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF678Nov 17, 2021

  Based on interview and record review, the facility failed to assess for a patent airway and attempt to clear an obstructed airway in an unconscious resident for 1 of 1 resident (R2) reviewed for emergency basic life support in the sample of five. This failure resulted in staff providing ineffective rescue breathing, and R2 subsequently expiring. The Immediate Jeopardy began on [DATE] at approximately 6:20pm, when V5 (Certified Nurse Assistant/CNA), upon finding R2 without pulse and respirations, placed a pillow under R2's head, did not visually check R2's airway for occlusion, and did not perform a finger sweep to check for airway occlusion, prior to beginning rescue breathing, subsequently resulting in R2's death on [DATE] at 6:51pm. […]

• Immediate jeopardy, patternF808Nov 17, 2021

  Based on interview and record review, the facility failed to serve a resident food consistent with a mechanical soft diet for 1 (R2) of 5 residents reviewed for therapeutic/mechanically altered diets in the sample of 5. This failure resulted in R2 aspirating a whole brussels sprout, with R2's airway becoming occluded, and R2 subsequently expiring. The Immediate Jeopardy began on [DATE] at approximately 5:45pm, when R2 was served a meal inconsistent with R2's prescribed mechanical soft diet. On [DATE] at approximately 6:20pm, staff found R2 unresponsive after having ingested a whole brussel sprout, which occluded his airway and caused R2 to stop breathing, subsequently resulting in R2's death on [DATE] at 6:51pm. […]

• Immediate jeopardy, isolatedF678Nov 4, 2025

  Based on interview and record review the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for 1 of 3 (R1) residents reviewed for death in the sample of 13. This failure resulted in facility staff not initiating CPR for R1 when R1 was found unresponsive on [DATE]. R1 was found unresponsive by V7 (Certified Nurse Assistant/CNA) and V8 (CNA). V8 notified V4 (Registered Nurse) that R1 was unresponsive. V8 asked V4 if R1 was a Full Code or DNR (Do Not Resuscitate), and V4 responded she did not know. V4 stated she did not initiate CPR because there was nothing in her chart saying R1 was a Full Code or DNR. R1's progress note dated [DATE] documents R1 was a full code. R1 was pronounced dead at the facility by V4 and V6 (Licensed Practical Nurse). […]

• Immediate jeopardy, isolatedF689Apr 21, 2025

  Based on interview, observation, and record review, the facility failed to prevent a cognitively impaired ambulatory resident (R1) from exiting the facility unwitnessed and without staff supervision for 1 of 3 residents reviewed for elopement in the sample of 3. This failure resulted in R1, unknown to staff, exiting the facility and walking approximately one block away, falling and sustaining a skin tear over his left temporal region and scattered abrasions over both hands, wrists, and elbows, and then entering a private citizens unlocked vehicle. R1 was treated at the local ER (emergency room ) for the skin tears and released later that evening. […]

• Actual harm, isolatedF760Apr 21, 2026

  Based on interview and record review, the facility failed to ensure that residents were free from medication errors for 2 (R6, R63) of 13 residents reviewed for medication errors in the sample of 51.This failure resulted in R63, after receiving monthly doses of injectable atypical antipsychotic on 1/31/26 and 2/5/26, experiencing extrapyramidal symptoms and sedation. These symptoms resulted in R63 being sent to the local ER (Emergency Room) and poison control being contacted. Findings include: 1. […]