Richmond Beach Rehab

In the surveyor’s words

From the most serious findings on record at Richmond Beach Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 17, 2022

  Based on observation, interview, and record review, the facility failed to follow and implement written policies and procedures, assessments, physician orders, plan of care, and evaluation related to smoking, and did not ensure smoking materials were securely maintained for 4 of 4 residents (Residents 38, 85, 49 & 76) for whom the facility had identified as smokers. The failure to ensure smoking materials were securely maintained for Resident 38 whose roommate was using oxygen in their room placed the residents at increased risk of serious harm and injury from potential fire hazards and risks of potential [CONDITION(S)]. […]

• Immediate jeopardy, isolatedF689Mar 15, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision during a meal for 1 of 3 residents (Resident 1) reviewed for supervision during mealtime. Failure to provide consistent and sufficient supervision during a meal for Resident 1 resulted in Resident 1's having respiratory failure (serious condition where lungs cannot get enough oxygen) related to aspiration (breathing in) of food into the airway, and subsequently died . A past noncompliance Immediate Jeopardy (IJ) was identified on [DATE] related to F689 Free of Accident Hazards/Supervision/Devices for failure to supervise a resident during mealtime. […]

• Actual harm, isolatedF689Aug 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe transportation was provided for 1 of 3 residents (Resident 45), reviewed for transportation to an appointment in the facility van. This failure caused harm when the wheelchair tipped over causing ongoing pain in Resident 45's left shoulder, arm, and hand. The failure to ensure the straps attached to the floor of the van were securely attached to the wheelchair before/after appointment transportation placed other residents at risk for injury and harm. Findings included . Review of Resident 45's quarterly Minimum Data Set assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident 45 was cognitively intact. […]

• Actual harm, isolatedF758May 17, 2022

  Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident 87) reviewed for unnecessary medications was free of unnecessary drugs. Failure to ensure the facility monitored behaviors the medications were intended to treat and ensure monitoring for Adverse Side Effects (ASEs) and consider pharmacy recommendations for Gradual Dose Reductions (GDRs), resulted in Resident 87 experiencing harm related to ASEs of medications prescribed. […]

• No harm, potential for more than minimal, widespreadF812Feb 25, 2026

  Based on observation, interview, and record review, the facility failed to ensure chlorine test strips (used to measure the concentration of free available chlorine in sanitizing solutions) were not expired in accordance with professional standards for 1 of 1 kitchen, reviewed for dinnerware sanitization and storage. This failure placed the residents at risk for unsanitary dining conditions and a diminished quality of life.Findings included .Review of the facility's policy titled Dishwashing Machine Use, revised in March 2010, showed, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation.During a joint observation and interview on… […]