Richmond Pines Healthcare and Rehabilitation Cente

In the surveyor’s words

From the most serious findings on record at Richmond Pines Healthcare and Rehabilitation Cente, in the surveyor’s own words.

• Immediate jeopardy, patternF686Jun 28, 2021

  3a) Resident #3 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's active care plan, last reviewed 4/1/21, included a focus area for admitted with pressure ulcer to sacrum and was at risk of developing further pressure areas related to immobility. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact and displayed no behaviors or refusal of care during the 7 day look back period. She required extensive assistance with Activities of Daily Living (ADL's) and was coded with 1 stage 3 pressure ulcer. The June 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Nov 18, 2021

  Based on observation, the Center for Disease Control (CDC) guidelines for the use of Personal Protective Equipment (PPE), CDC COVID-19 Data Tracker for Richmond County Transmission Rate, and staff interviews, the facility failed to wear eye protection when caring for residents for 4 of 4 halls (100, 200, 300 and 400 Halls). The findings included: Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 10, 2021 read as follows: Implement Universal Use of Personal Protective Equipment for Healthcare Personnel: If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care, healthcare personnel working in facilities located in counties with substantial or… […]

• No harm, potential for more than minimal, patternF755Dec 18, 2025

  Based on record review, and staff, Pharmacist, and Physician interviews, the pharmacy failed to provide the correct dose of Depakote (an anticonvulsant medication used to treat epilepsy) for a resident. This was for 1 of 6 residents reviewed for medications (Resident #53).The findings included:Resident #53 was admitted to the facility on [DATE] with diagnoses that included unspecified convulsions/epilepsy. Review of Resident #53's active orders revealed an order dated 03/16/25 for Depakote Sprinkle Capsule 125mg (milligram), give 2 capsules by mouth three times a day. […]

• No harm, potential for more than minimal, patternF760Dec 18, 2025

  Based on observations, record review, and staff, Pharmacist, and Physician interviews, the facility failed to administer the correct dose of Depakote (an anticonvulsant medication used to treat epilepsy). This was for 1 of 6 residents reviewed for medications. The findings included: Resident #53 was admitted to the facility on [DATE] with diagnoses that included unspecified convulsions/epilepsy. Review of Resident #53's active orders revealed an order dated 03/16/25 for Depakote Sprinkle Capsule 125mg (milligram), give 2 capsules by mouth three times a day unspecified convulsions.Resident #53's significant change Minimum Data Set (MDS) dated [DATE] indicated her cognition was severely impaired. She had no behaviors and no rejection of care coded. […]

• No harm, potential for more than minimal, patternF914Dec 18, 2025

  Based on record review, observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 1 of 3 residents reviewed for privacy (Resident #86).The findings included: Resident #86 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #86 was cognitively intact and provided personal care for herself with set-up and supervision. An observation of Resident #86's room on 12/16/25 at 2:40 PM, revealed no privacy curtains. Another observation of Resident #86's room occurred on 12/17/25 at 9:55 AM and revealed no privacy curtains were present.On 12/17/25 at 10:50 AM, an interview occurred with Resident #86. […]