The Reserve at Richardson

In the surveyor’s words

From the most serious findings on record at The Reserve at Richardson, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 10, 2025

  Based on observations, interview, and record review, the facility failed to ensure resident received adequate supervision to prevent Resident #1's accidents from an elopement for (Resident #1) 1 of 6 residents reviewed for wandering, elopement, accidents, hazards, and supervision. On 01/26/2025, the facility failed to identify potential hazards and follow internal systems in place for Resident #1 to prevent her from exiting thru unlocked doors located in the dining area leading to a corridor land fire exit door which connected to a stairwell where she experienced an unwitnessed fall down the stairs and sustained multiple serious injuries that included right wrist and extensive facial fractures. […]

• Immediate jeopardy, isolatedF686Oct 16, 2021

  Based on observation, interview, and record review the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for four (Residents #1, 11, #31, and #34) of ten residents reviewed for pressure ulcers. […]

• Actual harm, isolatedF689Apr 12, 2023

  Based on interviews and record reviews the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of twenty-two residents reviewed for falls. The facility failed to ensure the OT was trained to provide adequate assistance to prevent accidents for Resident #1 who was a two person assist with ADL care. As a result, the resident fell during an attempted transfer and was later taken to the hospital and found to have a tibial fracture. This failure could place the residents at risk for injury. Findings included: Review of Resident #1's face sheet dated 04/03/23 reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. […]

• No harm, potential for more than minimal, patternF565May 21, 2026

  Based on observation, interview and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 11 of 11 confidential residents reviewed for resident council.The facility failed to provide a private space for resident council meetings. This failure could place residents who attended the resident council meetings at risk of not being able to voice concerns due to lack of privacy. Observation and interview on 05/20/2026 at 11:30 a.m. during a confidential resident group meeting held in a private therapy gym, revealed the meeting was normally held in the upstairs dining room. There were no doors or solid walls that separated the dining room from the open nurses' station or the two hallways leading into the dining room. […]

• No harm, potential for more than minimal, patternF761May 21, 2026

  Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for six of twenty residents (Residents #29, #44, #70, #74, #78, and #86) and one of three carts (Nurse Cart) reviewed for medication storage. 1.The facility failed to ensure that Resident #78's eye drops were not accessible to other residents on 05/19/2026. 2.The facility failed to ensure that Resident #70 analgesic topical gel was not inside his room on 05/19/2026. 3.The facility failed to ensure that Resident #86 did not have a tube of zinc oxide inside her room on 05/19/2026. […]