The Health Center at Richland Place

In the surveyor’s words

From the most serious findings on record at The Health Center at Richland Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 25, 2024

  Based on facility policy review, medical record review, and interview, the facility failed to provide adequate supervision and assistance for 1 of 5 (Resident #1) sampled residents reviewed for accident hazards. Resident #1, a non-ambulatory resident with severe cognitive impairment, was left, unattended, sitting on the side of the bed, had an unwitnessed fall, and sustained multiple fractures (left femur, pelvis, left humerus, ribs, and vertebrae). Resident #1 was transferred to the hospital and admitted to level 3 trauma services. […]

• Immediate jeopardy, isolatedF726Mar 25, 2024

  Based on facility policy review, personnel record review, medical record review, and interview, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to ensure resident safety and attain or maintain the highest level of practicable physical well-being for 1 of 5 (Resident #1) sampled residents reviewed. On [DATE], Resident #1 (severely cognitively impaired, dependent upon staff for bed mobility assistance, and a high-risk for falls) was left, unattended, on the side of the bed, had an unwitnessed fall, and sustained multiple fractures (left femur, pelvis, left humerus, ribs, and vertebrae). Registered Nurse (RN) A and Certified Nursing Assistant (CNA) F immediately went to Resident #1's room and found the resident on the floor. […]

• No harm, potential for more than minimal, isolatedF550Aug 6, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote privacy for 2 of 5 (Resident #1 and Resident #4) sampled residents reviewed for dignity. The findings include: 1. Review of the facility's Patient Rights document in the admission handbook dated 9/2024, revealed .PRIVACY.we provide you with privacy so that you may maintain a dignified existence, self-determination, and communication with and access to persons and services inside and outside the center.People not directly involved in your medical care will not be present without your consent.Privacy is also maintained during toileting, bathing and other activities of personal hygiene.Each center shall respect a patient's right to the use and quiet enjoyment… […]

• No harm, potential for more than minimal, isolatedF695Aug 6, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for oxygen administration and failed to store, change, and date respiratory supplies for 2 of 3 (Resident #1 and #2) sampled residents reviewed for respiratory care. The findings include; Review of the facility's policy titled, Oxygen Administration, dated 2001, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration.Verify that there is a physician's order for this procedure. Review the physician's orders.for oxygen administration.Portable oxygen cylinder (strapped or secured in a stand). […]

• No harm, potential for more than minimal, isolatedF755Aug 6, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure Physician Orders were written and documented when 1 of 3 (Resident #1) sampled residents received medications without a written Physician Order for a respiratory breathing treatment. The findings include: 1. Review of the facility's policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES dated 2/25/2025, revealed .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Before administering a medication, the nurse should assure he/she is administering to the correct patient, verify the medication, dose, time and route .The medication administration record (MAR) is always employed during… […]