Richwood Nursing & Rehab

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 31, 2025

  Based on observation, interview, record review and review of facility policy, it was determined that the facility failed to prevent accidents for one (Resident (R) 19) of twenty-two sampled residents. On [DATE], R19, whose mobility was per wheelchair, fell from the back of a transport van when staff released the safety restraints before assuring that the hydraulic lift was in place. R19 flipped backwards over her wheelchair, falling over 10 feet from the van onto the pavement, landing headfirst. […]

• No harm, potential for more than minimal, patternF730Mar 13, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure performance review evaluations were completed for every Certified Nursing Assistant (CNA) at least once every 12 months for 4 out of 4 CNA's personnel records reviewed, CNA 21, CNA 22, CNA 23, and CNA 24. The findings include: Review of the facility policy titled, Staffing, Sufficient and Competent Nursing, revised August 2022, revealed Competency was defined as, a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. […]

• No harm, potential for more than minimal, isolatedF584Mar 13, 2025

  Based on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 33 sampled residents (Resident (R)16). Observation on 03/11/2025, 03/12/2025, and 03/13/2025 revealed multiple wheelchairs, wheelchair leg extenders and boxes observed on the other side of room from R16's bed. The findings include: Review of the facility policy, Homelike Environment, revised February 2021, revealed facility staff and management maximized, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting which included personalized furniture and room arrangements. […]

• No harm, potential for more than minimal, isolatedF623Mar 13, 2025

  Based on interview, record review and review of facility policy, the facility failed to send a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 sampled residents investigated for hospitalizations out of a total sample of 33 residents, (Resident (R)69 and R43). Review of R69's and R43's medical records revealed no documented evidence the facility provided notice of the residents' transfer to the hospital to the Office of the State Long-Term Care Ombudsman as required. […]

• No harm, potential for more than minimal, isolatedF656Mar 13, 2025

  Based on observation, interview, record review, and review of facility policy, the facility failed to implement the comprehensive person-centered care plan for 2 of 33 sampled residents (Resident (R)28 and R259). 1. On 12/09/2024 and 12/17/2024, R28 experienced a fall without injury, and the facility updated the resident's care plan with an intervention to educate staff to place dycem (a nonslip material used to stabilize objects) in the resident's wheelchair. 2. Additionally, the facility care planned R259 for one person assist with eating on 03/07/2025. […]