Tranquility of Richmond Heights

In the surveyor’s words

From the most serious findings on record at Tranquility of Richmond Heights, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF814May 28, 2025

  Based on observation and staff interview, the facility failed to maintain the dumpster area in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 48. Findings include: Observation on 05/18/25 at 8:25 A.M. with Dietary Manager (DM) #419 revealed the lid to the dumpster was open and the enclosure to the dumpster was left open. There was significant debris surrounding the dumpster inside the enclosure including cups, plastic wrap, gloves, and food wrappers. Interview on 05/18/25 at 8:25 A.M. with DM #419 confirmed findings of the dumpster area and indicated the maintenance director was responsible for maintaining the dumpster area.

• No harm, potential for more than minimal, widespreadF880May 28, 2025

  Based on record review, observation, interview, review of the Centers for Disease Control and Prevention (CDC) guidance on enhanced barrier precautions in nursing homes, and facility policy review, the facility failed to implement enhanced barrier precautions which required the use of gowns and gloves during care for residents with wounds or indwelling medical devices, which affected nine residents (#5, #12, #20, #23, #30, #34, #36, #45, and #46) out of 10 reviewed for transmission-based precautions (TBP) and enhanced barrier precautions. In addition, the facility failed to develop and implement a water management program and Legionella risk assessment, which had the potential to affect all residents residing in the facility. The facility census was 48. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF814May 18, 2023

  Based on observation and interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 34 residents. Findings include: Observation of the facility's garbage disposal area with Dietary Director #218 on 05/15/23 at 9:53 A.M. revealed both lids were open on the dumpster. There was some trash and leaves accumulated around the dumpster. Dietary Director #218 verified the above findings at the time of observation.

• No harm, potential for more than minimal, widespreadF881May 18, 2023

  Based on record review, interview, and facility policy review the facility failed to provide documented evidence an antibiotic stewardship program was in place. This affected six residents (#2, #21, #23, #32, #38, and #141) and had the potential to affect all 34 residents residing in the facility. Findings include: Review of the infection control documentation revealed no documented evidence that an antibiotic stewardship program was in place. Interview on 05/17/23 at 5:22 P.M. with the Director of Nursing (DON) and Administrator revealed antibiotic stewardship was stopped during the COVID-19 pandemic as the task was waivered and had not started back up yet. […]

• No harm, potential for more than minimal, widespreadF880Feb 13, 2023

  Based on observation, interview, record review and review of the online resources for Centers for Disease and Prevention (CDC), the facility failed to ensure staff properly used personal protective equipment (PPE) as required when entering or leaving Resident #35 and #34's room who were on precautions for COVID 19. This had the potential to affect all residents residing in the facility. The facility census was 43. Findings include: 1. Record review for Resident #35 revealed an admitted [DATE]. Diagnosis included hemiplegia and hemiparesis following cerebrovascular disease. Record review of the Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was cognitively intact. Resident #35 required extensive assistants of one with bed mobility and transfers. […]