The Health Center At Richland Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 of his or her personal room.patient's shall have the right to close the door to their room if they wish. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including…

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 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). Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Pneumonia, Acute Respiratory Failure, Congestive Heart Failure, and Nicotine Dependence. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact…

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 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 medication administration .the physician's orders are checked .Medications are administered in accordance with written orders of the prescriber . Review of the facility's Patient Rights document in the admission handbook revised…

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 policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote privacy of medical records for 2 of 3 (Resident #1 and Resident #3) sampled residents reviewed during medication administration. The findings include: Review of the facility's Patient Rights document dated 9/2024, revealed .MEDICAL RECORDS.A record kept of Physician's Orders, Progress Notes and Professional documentation which is called your Medical Record.your personal and medical records are kept confidential and are used only by individuals involved in your care. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Pneumonia, Acute Respiratory Failure, Congestive Heart Failure, and Nicotine Dependence. Observation on 2nd floor short hall across from the elevators on 8/4/2025 at 4:10 PM, revealed a medication cart with the laptop open showing Resident #1's personal information and medications on the laptop screen.…

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 policy review, Centers for Disease Control and Prevention Guideline (CDC) review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for medication administration for 3 of 3 (Resident #1, #2 and #3) sampled residents reviewed receiving medications, when 3 of 3 nurses (Registered Nurse (RN) A, RN B, and Licensed Practical Nuse (LPN) C) failed to clean the site prior to administering a transdermal patch, failed to perform hand hygiene before and after glove use, and failed to disinfect re-usable equipment. The findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated 2/2025, revealed .PURPOSE .To decrease the number of microorganisms, preventing cross contamination between staff and patients .Provide hand hygiene before and after contact with each patient .and before and after removal of gloves . Review of the facility's policy titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES: Transdermal Drug…

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 facility policy review, medical record review, and interview, the facility failed to implement appropriate interventions on the care plan for 1 of 5 (Resident #1) sampled residents reviewed. The findings include: Review of the facility's policy titled, Patient Care Plans, dated November 2023, revealed, .The center will ensure an interdisciplinary and comprehensive approach to the development of the patients care plan. Patient ' s goals and care preferences will be determined and used to develop their care plan of care .Baseline plan of care within 48 hours of admission addressing the immediate needs of the patient. Must be presented to patient and/or representative in terms they understand . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which include Type 2 Diabetes Mellitus, History of Falling, Contusion of Scalp, Subsequent Encounter, Alzheimer's Disease, Psychotic Disturbance, Mood Disturbance, Anxiety, Muscle Weakness, and Other Abnormalities…

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 ensure personal items were within the resident's reach for 1 of 38 residents (Resident #57) observed. The findings include: Review of the medical record revealed Resident #57 was readmitted to the facility on [DATE] with diagnoses which included Paroxysmal Atrial Fibrillation, Congestive Heart Failure, and Gout. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Care Plan dated 3/9/2020, revealed Resident #57 was care planned for .Encourage independence as much as possible/tolerated .Place personal items close to PT [patient] . Observation and interview conducted on 6/21/2021 at 11:29 AM, revealed the resident's reacher which stood upright against the nightstand and the back scratcher was on the table behind Resident #57 out of his reach. Resident #57 stated he wanted his reacher and his back scratcher but he…

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 facility policy review, medical record review, observation, and interview, the facility failed to implement a care plan for 1 of 11 residents (Resident #106) reviewed for Intravenous (IV) therapy. The findings include: Review of facility policy titled, Care Plan Development, revised 7/3/08, revealed, .B. Procedure: 13. Updating and Revising Care Plans- c. Other Changes: 1) New problems are handled as they arise, and are be added to the current care plan even if the change in condition is not considered significant enough for a complete revision . Review of the medical record, revealed Resident #106 was admitted to the facility on [DATE] with diagnoses which included, Hypertensive Heart Disease, Diastolic Congestive Heart Failure, and Permanent Atrial Fibrillation. Review of the Physician's Order Report dated 5/22/2021 - 6/22/2021, revealed Resident #106 had a physician's order dated 6/11/2021 for, .place midline once - One Time: 07:00 [7:00 AM] - 07:00 PM . Review of the Care Plan dated 6/15/2021,…

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 facility policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for 1 of 11 residents (Resident #50) reviewed for weekly intravenous dressing changes. The facility also failed to obtain physician's orders for 2 of 11 residents (Resident #84 and #106) reviewed for Intravenous (IV) therapy, and 1 of 29 residents (Resident #344) reviewed for oxygen therapy. The findings include: Review of the facility policy titled, Supplemental Oxygen, dated 1/2005, revealed .the purpose of delivering oxygen by nasal cannula is to .equipment: oxygen concentrator or stationary supply of oxygen .Procedure: check for a complete physician order, explain procedure to patient and family .Patient response to treatment: respiratory status and improvement, vital signs for stabilization or changes . Review of the facility policy titled, Oxygen delivered by Nasal Cannula, dated 10/1999 and revised 1/2005, .Procedure: 1. Check for a complete physician order . Review of the…

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 facility policy review, medical record review, observation, and interview, the facility failed to dispose of a used intravenous (I.V.) medication bag and tubing after administration for 1 of 11 residents (Resident #84) reviewed receiving I.V. therapy. The findings include: Review of the facility policy titled, Network Pharmacy Policy and Procedure; Preparation and General Guidelines, dated 1/1/2019, revealed, .Administer IV solution as directed and complete documentation .Discard used bag at the time of completion or when it is time for the next dose . Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Congestive Heart Failure, Chronic Atrial Fibrillation, and Muscle Weakness. Review of the Care Plan dated 6/18/2021 revealed Resident #84 was care planned for .Administer IV meds/fluids per order/s .Flush, clean and change caps per order .IV care per order-Assess IV dressing every shift for being loose, damp or visibly…

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 medical record review and interview, the facility failed to send notification of discharge/transfer to the Ombudsman for 3 of 3 (#23, #62, #91) residents reviewed. The findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses which included Orthopedic Aftercare, Dementia without Behavioral Disturbance and Hypertension. Medical record review of the Matrix Care resident census revealed Resident #23 was discharged /transferred to the hospital on 3/7/19. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses which included Heart Failure, Dependence on Supplemental Oxygen and Dysphagia. Medical record review of the Matrix Care resident census revealed Resident #62 was discharged /transferred to the hospital on 4/12/19. Medical record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses which included Orthopedic Aftercare, Multiple Sclerosis, Chronic Obstructive Pulmonary Disease…

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 facility policy review, medical record review, and interview, the facility failed to identify 1 of 33 residents (#55) prior to obtaining laboratory services. The findings include: Review of facility policy, Laboratory and Diagnostic Test Results-Clinical Protocol, dated 9/2012, revealed .The staff will process requisitions and arrange for tests . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Endometrium, Malignant Neoplasm of Genital Organs, Encounter for attention to Colostomy, Type 2 Diabetes Mellitus, Difficulty in Walking. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating resident was cognitively intact, understood others with clear comprehension, had adequate vision-saw fine detail, wore glasses, and had no behaviors. Medical record review of the Physician's orders for Resident #55 revealed no laboratory tests…

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 facility contract review, medical record review, and interview, the facility failed to have an interdisciplinary care plan between the hospice services provider and the facility for 1 of 8 residents (#55) receiving hospice services. The findings include: Review of a facility contract, Agreement between Hospice and Facility, dated 6/12/08, revealed .Hospice will prepare a care plan for that patient within two (2) working days and deliver a copy of it to the Facility . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Endometrium, Malignant Neoplasm of Genital Organs, Malignant Neoplasm of Other Specified Sites, Encounter for Attention to Colostomy, Type 2 Diabetes Mellitus without complications, Edema, and Difficulty in Walking. Medical record review of the Physician's orders, dated 6/4/19, revealed Hospice to evaluate and treat as indicated. Medical record review of the Nursing Care Plan, revised 6/11/19, revealed…

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.