Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Richmond Post Acute Care during CMS and state inspections, most recent first.
A facility failed to honor a resident's food preferences and revoked smoking privileges for three residents who adhered to smoking protocols. Despite a resident's dislike for chicken, they were served it, and three residents lost smoking privileges due to another's violation, without considering their compliance or psychosocial well-being.
The facility failed to involve two residents in their care planning process, despite their intact cognitive status and desire to participate. Both residents, admitted with muscle weakness and difficulty in walking, had not been included in care conferences, contrary to the facility's policy. The DON acknowledged the importance of these conferences, which should involve a multidisciplinary team and occur regularly.
The facility failed to ensure two residents were free from unnecessary medications. One resident was prescribed Levaquin without an adequate indication, and another was given Ciprofloxacin without a stop date or clear indication for continued use. The facility's policies on unnecessary medications and antibiotic stewardship were not followed.
The facility failed to ensure safe medication storage and labeling, affecting 28 residents. Expired and unlabeled medications were found in the medication refrigerator, and insulin pens were improperly stored. Medications were not separated by administration route, and narcotics were stored with personal belongings. These practices were acknowledged by staff as potentially leading to medication errors.
The facility failed to store food safely, with items beyond use-by dates and unlabeled resident food in the refrigerator and freezer. Staff food was improperly stored with resident food, risking cross-contamination. Staff interviews confirmed these practices violated facility policies.
A registered nurse failed to disinfect a medication tray and BP cuff between uses for multiple residents, contrary to the facility's infection control policy. The nurse intended to clean the equipment after completing all tasks, but this practice was not in line with the immediate cleaning requirement to prevent cross-contamination.
The facility had seven resident rooms with multiple beds that did not meet the required space of at least 80 square feet per resident. Rooms with two beds provided only 77 square feet per resident, and rooms with three beds provided only 73 square feet per resident. Despite this, observations showed sufficient space for care, no heavy equipment interference, and no resident complaints or safety concerns.
Failure to Honor Resident Preferences and Rights
Penalty
Summary
The facility failed to honor the food preferences of Resident 15, who was admitted with a diagnosis of difficulty in walking and had a BIMS score indicating intact cognitive status. Despite the resident's clear dislike for chicken, as noted on their meal ticket, they were served chicken parmesan for lunch, which they did not eat. This oversight was acknowledged by a kitchen staff member and the registered dietician, who confirmed that the facility's policy is to respect residents' food preferences and provide alternatives to disliked foods. Additionally, the facility did not allow Residents 5, 9, and 13 to continue smoking, despite their adherence to the facility's smoking policy. These residents, who had been assessed as safe to smoke with supervision, were informed that smoking privileges were revoked due to another resident's violation of the smoking protocols. Interviews with the residents and staff, including the social worker and director of nursing, revealed that the decision to discontinue smoking privileges was made without considering the individual compliance of these residents or assessing their psychosocial well-being after the policy change. The administrator confirmed that the smoking privileges were revoked due to safety concerns and staffing limitations, despite the fact that the compliant residents followed all smoking protocols. The facility's policy allows for smoking restrictions if a resident cannot smoke safely with available supervision, but the decision to impose a blanket ban did not take into account the dignity and rights of the residents who adhered to the rules. The facility's policies on resident rights and smoking were not fully aligned with the actions taken, leading to the deficiency.
Failure to Include Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 22 and Resident 77, participated in their care planning process. Both residents were admitted to the facility in December 2024, with Resident 22 diagnosed with muscle weakness and Resident 77 with difficulty in walking. Despite having intact cognitive status, as indicated by their BIMS scores of 15, neither resident was involved in a care conference to discuss their plan of care. Interviews with both residents revealed their dissatisfaction and desire to participate in their care planning, which had not occurred. The Director of Nursing acknowledged the importance of care conferences, which should involve a team including nurses, nursing assistants, social services, residents, responsible parties, and doctors. These conferences are meant to occur on admission, quarterly, after any significant change, and as needed. However, a review of the medical records confirmed that care conferences for Residents 22 and 77 had not been conducted. The facility's policy encourages resident and family participation in care planning, yet this was not adhered to, leading to the deficiency.
Failure to Ensure Residents' Drug Regimens Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident 4 was prescribed Levaquin, an antibiotic, without an adequate indication for its use. The order was for a congested cough, which the Infection Preventionist (IP) and Director of Nursing (DON) acknowledged was not a correct indication for antibiotic use. The licensed nurse who entered the order did not include the correct indication, leading to the potential for unnecessary medication use. Resident 22 was prescribed Ciprofloxacin, another antibiotic, without a stop date and without a clear indication for its continued use. The resident was initially treated for Peritonitis, but the condition had resolved according to the Medical Director's note. Despite this, the antibiotic was continued indefinitely based on a hospital order, and the Consultant Pharmacist's recommendation to reassess the duration was still pending. The facility's policy on unnecessary medications and antibiotic stewardship was not followed, as there was no adequate indication or stop date for the antibiotic use.
Improper Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe medication storage and labeling practices, affecting a census of 28 residents. During an observation, it was found that the medication refrigerator contained five bags of expired and discontinued intravenous medications belonging to a resident who was no longer taking them. Additionally, an unlabeled, undated, and unsecured prefilled pen of Ozempic was found in the refrigerator, with no indication of which resident it belonged to. These practices were acknowledged by the Infection Preventionist (IP) as potentially leading to medication errors. Further observations revealed that an expired insulin pen was stored in an active storage area of the medication cart, and an unopened insulin pen labeled for refrigeration was stored at room temperature. A small bottle of Nitroglycerin belonging to a discharged resident was also found in the medication cart. These storage issues were confirmed by a Registered Nurse (RN), who admitted that these practices could lead to medication errors and reduced potency of the medications. The facility also failed to separate medications by administration route, as evidenced by the storage of topical ointments and creams with oral and inhalation medications. Narcotic medications were improperly stored with residents' personal belongings, such as cigarettes and money. The Director of Nursing (DON) and the Consultant Pharmacist (CP) both acknowledged these deficiencies, emphasizing the importance of proper labeling, storage by administration route, and separation of personal items from medications to prevent contamination and medication errors.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to ensure that food was stored under safe and sanitary conditions, as observed during a survey. Refrigerated and frozen food items were found to be stored beyond their use-by dates, including a container of olives, sweet potatoes, and a pack of garden burgers. Additionally, resident food items in the refrigerator and freezer were unlabeled and undated, such as a bag of ready-to-eat salad, a bottle of coffee creamer, and opened water bottles. Staff food items were also improperly stored in the resident refrigerator, which included three staff lunch bags, posing a risk for cross-contamination. Interviews with facility staff, including a cook, an infection preventionist, and a registered dietician, confirmed these practices were against the facility's policies. The staff acknowledged that food beyond its use-by date should be discarded to prevent illness, and resident food should be labeled with names and dates to track freshness. The facility's policies from 2014 and 2018 emphasized the importance of proper food storage, labeling, and separation of staff and resident food to comply with safe food handling practices.
Failure to Disinfect Equipment Between Uses
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration and blood pressure monitoring for four residents. During observations, a registered nurse (RN) was seen using a medication tray and blood pressure (BP) cuff on multiple residents without disinfecting them between uses. Specifically, the RN used the same medication tray and BP cuff for Residents 9, 3, 129, and 22 without cleaning them after each use, which is against the facility's policy and procedure for sanitizing equipment. The RN admitted to not cleaning the equipment after each use, intending to do so after completing all tasks. The Infection Preventionist confirmed that all reusable items should be disinfected with the facility's approved disinfectant to prevent cross-contamination. The facility's policy clearly states that all reusable equipment should be cleaned immediately after each use, which was not adhered to in this instance.
Resident Rooms Below Required Space Standards
Penalty
Summary
The facility was found to have seven resident rooms with multiple beds that did not meet the required space of at least 80 square feet per resident. Specifically, rooms with two beds provided only 77 square feet per resident, and rooms with three beds provided only 73 square feet per resident. This deficiency was identified during a record review of the Client Accommodations Analysis and through observations conducted over several days. Despite the space deficiency, observations indicated that there was sufficient space for the provision of care, and no heavy equipment was present in the rooms that could interfere with resident care. Residents had adequate personal space and privacy, and there were no complaints from residents regarding insufficient space for their belongings. Additionally, there were no negative consequences or safety concerns reported as a result of the decreased space in the identified rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vale Healthcare Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Creekside Healthcare Center | 0.9 mi | ★★★★★ | 3 | 0 |
| San Pablo Healthcare & Wellness Center | 1.2 mi | ★★★★★ | 5 | 0 |
| Shields Richmond Nursing Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Greenridge Post Acute | 2.9 mi | ★★★★★ | 0 | 0 |
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