Medilodge of Richmond

This citation pertains to intake 1183138.Based on observation, interview and record review, the facility failed to ensure sufficient staff to provide timely care to seven (R5, R18, R33, R34, R40, R95, and R99) of 24 residents. Findings include: On 07/21/25 at 9:38 AM during the initial screening of the facility residents: R95 reported Sometimes there is a long wait, like a half hour or more, when you push the call light for staff to come help you. R95 reported, It takes a half hour or so for call lights to be answered. R95 further reported they required assistance to eat and some staff don't like to feed (the residents). On 07/21/2025 at 10:19 AM, R33 was sitting up in bed dress in a hospital style gown. R33 reported concerns about not enough briefs and not enough staff. R33 reported they have waited longer than 30 minutes to get out of bed when they ask because they are a two-person transfer and their CNA has to go to another hall to get help. On 07/21/2025 at 10:30 AM, R5 was observed to be in bed connected to a tube feeding pump. The pump had a screen which read inactive and made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 1183138Based on observation, interview, and record review, the facility failed to ensure necessary grooming and hygiene (shaving and nail care) was provided for two (Residents #40 and #13) of four residents reviewed for activities of daily living (ADLs) assistance. Findings include:R40On 07/21/2025 at 10:49AM, R40 was observed lying supine in bed with the head of the bed slightly elevated. R40's fingernails were irregular in length, some approximately a quarter inch past the tip of the finger, and visibly dirty. R40 was unshaven with an approximate eighth inch black stubble, and the toenails were long (eighth to quarter inch beyond the tips of his toes) and crusted. On 07/22/2025 at 3:20 PM, R40 was asked about facial hair and nails and R40 reported they preferred to be clean shaven and have their fingernails and toenails trimmed and kept clean. On 07/22/2025 at 3:25 PM, R40 was observed being repositioned and provided incontinence care by Certified Nursing Assistant's (CNA) M…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that ordered laboratory work was completed for one (R34) of three residents reviewed for laboratory services. Findings include:A review of the medical record for R34 revealed they were admitted to the facility on [DATE] with diagnoses of high blood pressure, atrial fibrillation, respiratory failure and diabetes. The care plan, dated 09/25/2023, identified the resident as having impaired cardiovascular status and diagnostic testing should be completed as ordered. An order for routine laboratory testing, including a complete blood count (CBC/Diff) with differential, and comprehensive metabolic panel (CMP) was entered for R34. Documentation date 02/28/2025 indicated the lab was unable to obtain a sufficient blood sample, noting, Couldn't get a vein quantity not sufficient. A review of the medical record revealed no evidence that a follow-up attempt was made to redraw the laboratory tests, and there was no documentation to indicate the physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure meals were palatable and served in a timely manner for six residents (R21, R27, R33, R38, R99, R118) reviewed for food concerns from a census of 119 residents. Findings include:On 07/21/25 at 10:06 AM, during the initial screening, R21 reported their breakfast was cold today. On 07/21/2025 at 10:19 AM, during the initial screening, R33 stated, The food sucks. On 07/21/25 at 10:45 AM, R27 reported, they take good care of me, but the food is terrible, dried-up meat and almost choked on a hot dog. On 07/21/25 at 10:08 AM, R38 reported the meat can be tough and chewy, the eggs are served cold, and the Caesar salad was made with iceberg lettuce and served with Italian or ranch dressing. On 07/21/2025 at 10:40 AM, R99 reported the food is cold at one meal or another almost every day. R99 went on to say the oatmeal was served without brown sugar when requested so they had to buy their own; Staff can't or don't read the food tickets so R99 does not receive what is requested; They do not always get cereal or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, homelike environment for three residents R9, R31, and R60 out of three residents reviewed for environment. Findings include: R9 On 06/11/24 at 9:30 AM, R9 was observed lying in bed in their room watching television. An observation of the privacy cubical curtains revealed several round brown stains on it. When asked about the dirty curtains, R9 nodded his head and stated clean. A record review revealed that R9 was admitted on [DATE] with the medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side; Chronic Obstructive Pulmonary Disease, Apasia and Muscle Weakness. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 0 which indicates impaired cognition. R31 On 6/11/24 at 9:32 AM, R31 was observed lying in bed in their room watching television. An observation of the privacy cubical curtains…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00143507. Based on observation, interview, and record review, the facility failed to provide twice weekly showers for one (R33) of five residents reviewed for showers. Review of the facility record for R33 revealed an admission date of 06/12/23 with diagnoses that included Multiple Sclerosis, Neuromuscular Dysfunction of the Bladder and Urinary Tract Infection. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] was scored 15/15 indicating intact cognitive function. On 06/11/24 at 11:15 AM, R33 reported they had not consistently been assisted with a shower twice weekly as they had in the past. R33's spouse was on speaker phone at the time of the interview and reported they visit regularly and stated I know [R33] doesn't always get a shower twice a week. On 06/12/24 at 1:26 PM, R33 was observed to appear generally well groomed and clean. When asked about the frequency of being showered R33 stated I just had one on Sunday. I got them (showers) on the regular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to administration an intravenous (IV) antibiotic as ordered for one resident (R105) out of two reviewed for IV antibiotic use, resulting in missing eight doses of IV antibiotics. Findings Include: On 06/11/24 at 11:35 AM, R105 reported when they were admitted into the facility, they were on IV antibiotics and the medication ran out and they were without the treatment for at least a day. A review of the medical record revealed that R105 admitted into the facility on 5/8/2024 with the following diagnoses, Acute Osteomyelitis, Right Ankle and Foot and Non-Pressure Chronic Ulcer of Right Heel and Midfoot with Fat Layer Exposed. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental status score of 15/15 indicating an intact cognition. R105 also required assistance with bed mobility and transfers. Further review of the physician orders revealed the following orders; -Ampicillin-Sulbactam Sodium Injection Solution Reconstituted 3 (2-1) GM (Ampicillin & Sulbactam Sodium) Directions: Use 3 gram intravenously…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed and ensure residents on oxygen had full oxygen tanks available for three residents (R8, R59, R39) out of three residents reviewed for respiratory care. Findings include: R8 On 06/11/24 at 10:06 AM, R8 was observed sitting in their wheelchair at the sink in room. R8's oxygen tubing on the back of their wheelchair was in a bag and dated 5/28/24. Additional oxygen tubing was attached to a portable oxygen tank and dated 5/14/24. The oxygen tank on the back of the wheelchair was empty. R8 was not wearing oxygen at this time. On 06/11/24 at 12:17 PM, R8 was observed sitting in their wheelchair in the hallway. The oxygen tubing on the back of the wheelchair was still dated 5/14/24 and the oxygen tank was empty. R8 was not wearing oxygen at this time. On 06/12/24 at 08:18 AM, R8 was observed awake lying in bed using oxygen at two liters per nasal cannula (NC) by concentrator. Portable oxygen tank on back of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement interventions for reducing and/or eventually discontinuing the use of a restraint, and document and provide ongoing monitoring and evaluation for the continued use of a physical restraint for one sampled resident (R69), of one resident reviewed for restraints resulting in the potential for physical and psychosocial harm using the reasonable person concept. Findings include: On 6/5/23 at 12:47 PM, R69 was observed asleep in a Posey bed (a tent-like enclosure entirely covering a hospital bed. Someone on the outside of the bed must unzip one of the tent flaps before the individual can get out of the bed). A review of R69's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Schizophrenia, Developmental Disorder of Speech and Language, Seizures, and Anxiety. A review of R64's Quarterly Minimum Data Set (MDS) assessment dated for 3/25/23 revealed that the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake M100137029. Based upon observation, interview and record review, the facility failed to implement/document the care plan for repositioning frequency for one (R26) of two residents reviewed for repositioning, resulting in increased potential for skin breakdown. Findings include: Review of the facility record for R26 revealed an initial admission date of 08/02/17 and a most recent admission of 05/25/23 following hospitalization with diagnoses that included Multiple Sclerosis, Paraplegia and Epilepsy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R26 requires total assistance for bed mobility and all self care. The Brief Interview for Mental Status score was not recorded. R26 did not communicate verbally with the surveyor and did lightly nod their head at times in response to questions. Review of R26's Care Plan dated 03/22/23 revealed the Focus area description The resident has potential for impairment to skin integrity related to fragile skin, immobility secondary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were positioned appropriately during meals affecting two (R35 and R61) reviewed for the dining task, resulting in resident difficulty with self-feeding. Findings include: R61 On 6/5/23 at 12:49 PM, R61 was observed in their bed. R61's lunch tray was in front of them on the overbed table, however, the resident was slumped all the way over to their left side. R61 was holding an empty cup. A piece of cake was observed to have dropped out of the cup and onto the resident's bed. R61 expressed that they felt terrible. R61 was asked if they were comfortable. R61 asked why and stated, Because I'm sitting crooked? R61 then straightened themselves upright somewhat, but was unable to position themselves completely upright. On 6/5/23 at 1:20 PM, R61 remained completely slumped over to their left side in bed. R61's call light was noted to be on their right side, but the resident was unable to locate it. R61's cup of coffee had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00135394. Based on observation, interview, and record review, the facility failed to provide timely incontinence care to one resident (R35), and provide and document showers for one resident (R38) of 10 reviewed for activities of daily living (ADLs) resulting in soiled bedding, unmet care needs, resident discomfort, and the potential for skin breakdown. Findings include: A review of R35's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on 1/19/2021 and most recently readmitted on [DATE]. R35's medical diagnoses include Dementia, Heart Disease, Diabetes, Seizures, Malnutrition, Muscle Weakness, and Abnormal Posture. Further review revealed that the resident is severely cognitively impaired and requires extensive assistance for toilet use and is always incontinent of bowel and bladder. On 6/6/23 at 11:41 AM, R35 was observed lying in bed, surrounded by positioning pillows and covered with a blanket. R35 expressed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide and document repositioning of one sampled resident (R54) of two residents reviewed for positioning and skin management resulting in, the resident developing a facility acquired Deep Tissue Injury (DTI), pain, and the potential for the worsening/development of pressure ulcers. Findings Include: On 6/5/23 at 9:28 AM, R54 was observed in bed lying flat on their back, and asked how they were feeling on this date. R54 explained that they were uncomfortable due to be constipated, and had recently developed skin breakdown on their tailbone which causes them discomfort. R54 was asked if they had the skin impairment prior to being admitted into the facility, and they stated, No. R54 was asked about interventions being put into place to assist with healing the skin, and explained that they were recently provided a low air loss mattress, and is supposed to be seen by the wound care nurse. R54 was asked if they can reposition themselves, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.