Richmond Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF755Nov 13, 2023

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 16 of 18 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, and Resident #16) reviewed for pharmacy services. […]

• Immediate jeopardy, isolatedF684Nov 6, 2021

  Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 6 residents (CR #1) reviewed for quality of care. 1. The facility failed to timely identify CR #1's change in condition of lethargy, impaired communication and motor functions. 2. The facility failed to timely assess, notify CR #1's physician, and provide interventions to CR #1 who began to have an increased altered mental state, lethargy and physical impairments. 3. The facility failed to timely address CR #1's increase in [CONDITION(S)] activity. An Immediate Jeopardy (IJ) situation was identified on 11/3/21. […]

• Actual harm, isolatedF600Aug 7, 2026

  Based on, interviews, and record review, the facility failed to ensure each resident was free from abuse for 5 of 15 residents (Residents #9, #3, #5, #2 and CR #3) reviewed for abuse in that: 1. Resident #5 was physically abusive to Resident #9 on 7/22/26 when Resident $5 pushed Resident #9 to the ground and Resident #9 fell and hit her head, resulting in a 1.2 cm laceration. 2. Resident #5 was physically abusive to CR #3 on 6/24/26, when Resident #5 hit CR #3 causing CR #3 to put Resident #5 in a chokehold and they both fell to the floor. 3.Resident #2 was physically abusive to Resident #1 on 4/4/26 when Resident #2 hit Resident #1 on the left arm. These failures placed residents, who resided in the facility at risk of abuse, injuries, pain and emotional distress. The findings included:1. […]

• Actual harm, isolatedF755Jun 2, 2022

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's [MEDICATION(S)] medication was ordered from the pharmacy and received timely, as a result Resident #1's Tardive Dyskinesia worsened. This failure could place residents whose medications were supervised by the facility at risk of experiencing serious side effects from possible interruptions to their medication regimen. […]

• Actual harm, isolatedF760Jun 2, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for medications. Resident #1 experienced exacerbated symptoms of her illness with involuntary movements of her tongue and legs after she missed six doses of [MEDICATION(S)] medication because the facility failed to order it before it ran out. This failure placed all residents whose medications were supervised by the facility at risk of experiencing serious side effects from possible interruptions to their medication regimen. Findings included: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. […]