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 Shields Richmond Nursing Center during CMS and state inspections, most recent first.
A resident with traumatic brain injury, hemiplegia/hemiparesis, and moderately impaired cognition (BIMS 9) was discharged for reported clinical improvement and transferred to another SNF at the request of the responsible party, who did not want the resident to remain and sought more rehab therapy. Social services and the Admin acknowledged that, although an admission agreement letter was sent, the facility did not obtain or document confirmation that the receiving facility had accepted the resident before discharge. As a result, the resident was not admitted by the receiving facility and was instead sent to a GACH ED, contrary to facility policy requiring specific criteria, notification, orientation, and documentation for facility-initiated transfers/discharges.
A resident with moderately impaired cognition, traumatic brain injury, and hemiplegia who required maximal assistance for bathing did not receive scheduled twice-weekly showers on multiple occasions, according to facility documentation. The shower schedule required showers on specific days, and facility policy required staff to offer showers as scheduled, document any refusals with reasons and interventions, and notify the supervisor and physician as appropriate. CNA and DON interviews confirmed these expectations, but the DON could not provide documentation that showers were offered as scheduled or that refusals and required notifications were recorded.
The facility failed to consistently prepare palatable, flavorful meals, as evidenced by a resident reporting that facility food was sometimes inedible, including hard French fries and meat too tough to cut, leading the resident to keep personal food at bedside. The recently hired Dietary Supervisor stated she was unaware of food concerns, while the RD acknowledged prior complaints about overly salty food. During a test tray review, the brussels sprouts were bland, the turkey was salty, and the mashed potatoes were not creamy, which the Dietary Supervisor attributed to the use of bagged frozen potatoes.
Four residents did not receive necessary assistance with ADLs, including nail care and scheduled repositioning. Two residents with cognitive impairment and one with visual impairment had long, dirty fingernails, and staff confirmed that nail care was not provided as required. Another dependent resident was not turned and repositioned every two hours as outlined in the care plan, with staff interviews revealing this task was omitted from daily routines and documentation.
Three residents did not receive prescribed medications or appropriate care as ordered, including anti-hypertensives and other essential treatments. Staff held medications without physician orders, failed to notify physicians of elevated blood pressure or repeated medication refusals, and did not inform responsible parties when a resident with cognitive impairment refused medications. These actions were not in accordance with professional standards or facility policy.
Three residents experienced medication administration errors, including receiving the wrong type of multi-vitamin, missing a prescribed oral care medication during the scheduled pass, and delayed blood sugar monitoring with subsequent insulin administration. Nursing staff acknowledged the errors, which resulted in the facility's medication error rate exceeding 5 percent.
Two expired medications, Rocklatan eye drops and Humalog insulin, were discovered in a medication cart during an audit with an RN, who confirmed their expired status while assisting with medication administration. Facility policy requires outdated medications to be returned or destroyed, but these remained accessible in the cart.
The facility did not employ a qualified Dietary Services Manager when the Registered Dietitian was not present, resulting in unqualified staff overseeing dietary services and improper food preparation and storage for 64 residents. The Dietary Service Supervisor lacked required certification, and the Nutrition Support Specialist, who covered in the RD's absence, was not a qualified RD.
Surveyors found that food was prepared in a three-compartment sink, open pasta was not stored in airtight containers, and spoiled produce was kept unlabeled or undated. A dented can was stored with usable canned goods, and a can opener had visible rust. These actions did not comply with facility policies for food safety and sanitation.
A CNA transferred a resident with severe cognitive impairment and physical limitations from bed to wheelchair using a Hoyer lift without the required second staff member, contrary to the resident's care plan and facility policy. The DON confirmed that this action increased the risk of falls.
A resident with severe cognitive impairment, malnutrition, and pressure injuries consistently refused or consumed minimal food and fluids over several days, with intake records showing amounts far below recommended levels. Despite clear signs of inadequate nutrition and hydration, staff did not promptly notify the RD or physician, nor did they document interventions or inform the responsible party in a timely manner. Laboratory results later confirmed severe dehydration, and facility policies requiring prompt reporting and assessment were not followed.
Nursing staff failed to complete required annual competency evaluations, resulting in improper infection control practices and inadequate response to changes in residents' conditions. For example, a resident with C. diff infection did not have proper contact precautions implemented, and another resident experiencing multiple episodes of diarrhea did not receive appropriate assessment or testing. The DON confirmed that the RN had not completed the annual skills check, which could lead to significant errors.
Housekeeping and nursing staff did not use the required bleach-based disinfectants for cleaning a contact precaution room and medical devices used by a resident with C. diff infection. Instead, non-bleach cleaning agents and bleach-free wipes were used, contrary to facility policy and manufacturer recommendations for effective C. diff spore elimination.
A resident was given antibiotics for a history of urinary tract infections without proper diagnostic evidence, and staff failed to monitor for side effects such as diarrhea. Documentation showed repeated episodes of diarrhea, but there was no consistent follow-up or testing, and staff were not always aware of the resident's symptoms. The facility did not adhere to its own antibiotic stewardship policy or established clinical criteria before prescribing antibiotics.
The facility did not provide the required 80 square feet per resident in 12 multi-bed rooms, with measurements showing each resident had less than the minimum space. Although one resident noted the room felt small, others reported no issues, and care provision was not impacted during observations.
A facility failed to maintain proper infection control when a nurse did not perform hand hygiene between glove changes during a wound dressing change for a resident with a Stage III pressure ulcer. The nurse cleansed the wound and applied Santyl without washing hands between glove changes, contrary to the facility's hand hygiene policy. The DON acknowledged that this practice increases infection risk.
The facility failed to provide timely dental services for two residents, leading to potential health risks. One resident with a chipped tooth did not receive a dental referral within the required three days, while another resident experienced a significant delay in obtaining replacement dentures. The facility's policy requires referrals for damaged or lost dentures within three days, but this was not followed, contributing to the delay in addressing the residents' dental needs.
The facility failed to protect a resident from physical abuse when another resident repeatedly hit them on the legs. The abused resident, with Alzheimer's dementia and impaired vision, reported feeling unsafe. The aggressive resident had a history of similar behavior, and staff witnessed the incident, leading to the separation of the two residents.
Unsafe Discharge Without Confirmed Acceptance by Receiving Facility
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was transferred to another skilled nursing facility without confirmed acceptance from the receiving facility. The resident had a history of traumatic brain injury, hemiplegia/hemiparesis, and a BIMS score of 9, indicating moderately impaired cognition, though they were able to make themselves understood and understand others. The resident’s admission MDS documented difficulty recalling the correct year, month, and day of the week. A Notice of Proposed Transfer/Discharge dated 1/2/26 stated the transfer or discharge was appropriate because the resident’s health had improved sufficiently so that they no longer required the services provided by the facility. Interviews revealed that the resident’s responsible party requested transfer to another nursing home because they did not want the resident to remain at the current facility and wanted more rehabilitation therapy. The SS staff member stated the responsible party did not like the facility and confirmed that the facility did not receive confirmation from the receiving facility of the resident’s admission before discharge and transfer occurred. The DON stated the facility had provided physical, occupational, and speech therapy as ordered and that a referral for more therapy had been denied. The Administrator reported that a letter of admission agreement was sent to the receiving facility but could not provide documentation that admission had been confirmed prior to discharge. As a result, the resident was not accepted for admission at the receiving facility and was sent to a GACH emergency department. The facility’s policy on facility-initiated transfer or discharge stated that residents have the right to remain in the facility and that such transfers must meet specific criteria and require notification, orientation, and documentation.
Failure to Provide and Document Scheduled Showers and Hygiene Care
Penalty
Summary
The facility failed to provide scheduled shower services and to maintain grooming and personal hygiene for one of three sampled residents. The resident had an admission MDS dated 12/2/25 showing a BIMS score of 09, indicating moderately impaired mental status, and required maximal assistance for showers, with the helper performing more than half of the effort, including lifting and holding the trunk or limbs. The resident’s diagnoses included traumatic brain injury and hemiplegia/hemiparesis related to stroke. The facility’s AM Shift Shower Schedule, dated 5/2020, indicated the resident was to receive showers twice weekly on Wednesdays and Saturdays. A review of the Documentation Survey Report for December 2025 showed the resident did not receive showers on 12/6/25, 12/13/25, 12/17/25, and 12/24/25, despite being scheduled. CNA 1 stated that the facility process was to provide showers as scheduled, complete shower sheets, document refusals, and notify the charge nurse. The DON confirmed that staff were expected to offer showers twice weekly and, if refused, to notify the charge nurse and document the refusal in the resident’s record. The DON was unable to provide documentation that showers were offered as scheduled or that refusals and notifications were recorded. The facility’s policy on Bath, Shower/Tub, revised February 2018, required documentation of refusals, reasons, interventions taken, the signature and title of the person recording, and notification of the supervisor and physician as appropriate.
Failure to Prepare Palatable and Flavorful Meals
Penalty
Summary
The facility failed to ensure food was prepared by methods that conserved flavor and maintained palatability, attractiveness, and safe, appetizing temperatures, placing residents at risk of unplanned weight loss due to poor food intake. During an interview, one resident, who was awake and verbally responsive while lying in bed, reported keeping his own stack of food at his bedside because the food served by the facility was sometimes not edible. He stated that French fries were hard and could not be eaten, and that meat served for dinner was very tough and could not be cut with a knife. He reported having informed nursing staff and the Dietary Supervisor of these concerns. The Dietary Supervisor, who stated she was recently hired, reported she was not aware of any food concerns, while the Consultant Dietician, also recently hired, stated she was aware of complaints about food being salty and had discussed this with the former Dietary Supervisor. During a test tray observation with the Dietary Supervisor, the brussels sprouts were found to be bland, the turkey was salty, and the mashed potatoes were not creamy; the Dietary Supervisor acknowledged the brussels sprouts were bland and explained the mashed potatoes were not creamy because they were made from bagged frozen potatoes. These observations, interviews, and record reviews demonstrate that the facility did not consistently prepare food in a manner that conserved flavor and ensured palatability, contributing to resident dissatisfaction with meals and concerns about food quality.
Failure to Provide Required ADL Care: Nail Hygiene and Repositioning
Penalty
Summary
Four residents did not receive appropriate assistance with activities of daily living (ADLs), specifically in the areas of personal hygiene and mobility. Two residents with cognitive impairment and one with visual impairment were observed to have long fingernails with black matter underneath, and one had overgrown fingernails. These residents required at least partial assistance with personal hygiene, as documented in their assessments. Staff interviews confirmed that nail care was not provided as required, and in one case, a CNA incorrectly stated that a resident refused care, which the resident denied. Nursing staff acknowledged the importance of nail care, especially for residents with conditions such as diabetes and a history of scratching wounds, but confirmed that care was not provided. Another resident, who was dependent on staff for all ADLs due to severe cognitive impairment and physical limitations, was not turned and repositioned every two hours as indicated in the care plan. Observations showed the resident remained in the same position for several hours. Staff interviews revealed that the repositioning task was not included in the daily task list or electronic health record for this resident, resulting in the omission of this essential care activity. Both CNAs and RNs acknowledged the importance of regular repositioning for this resident. Facility policy and procedure documents reviewed by surveyors indicated that daily cleaning and regular trimming of fingernails, as well as scheduled repositioning for dependent residents, are required to prevent infection and skin breakdown. The Director of Nursing confirmed that the lack of nail care and repositioning placed residents at risk for infection and skin injury, and that the required care was not provided according to facility policy.
Failure to Administer and Manage Medications According to Orders and Resident Needs
Penalty
Summary
Three residents experienced deficiencies in the administration and management of their prescribed treatments and medications. One resident with a history of hypertensive emergency, end-stage renal disease, and other significant comorbidities did not receive multiple prescribed medications, including anti-hypertensives, stool softeners, and phosphate binders, on numerous occasions. The medication administration records showed repeated omissions of these medications, with staff documenting the reason as "Other/See Progress Notes." Interviews with nursing staff revealed that medications were routinely held on dialysis days without a physician's order to do so, and there was no documentation supporting this practice. Blood pressure readings before and after dialysis were consistently elevated, and the Director of Nursing confirmed that medications should have been administered as ordered or the timing adjusted appropriately. Another resident with end-stage renal disease, a history of stroke, and hypertension had multiple episodes of elevated blood pressure that were not addressed according to facility policy. The care plan required monitoring and reporting of malignant hypertension and medication side effects, but the medical record showed no documentation that the physician was notified when the resident's blood pressure exceeded the facility's threshold for notification. The resident reported not receiving blood pressure medication on one occasion and was told by a nurse to request it directly. The nurse admitted to not notifying the physician of repeated refusals, and the DON confirmed that no documentation existed of physician notification during periods of significantly elevated blood pressure. A third resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and neuromuscular bladder dysfunction, refused oral medications multiple times, including tamsulosin, zinc sulfate, and melatonin. The resident's medical record indicated that staff explained the risks and benefits of the medication, but the resident was not capable of understanding due to cognitive impairment. There was no documentation that the physician or responsible family members were notified of the repeated refusals, despite facility policy requiring notification after two or more consecutive refusals. The resident's responsible party was unaware of the refusals and stated this was not typical behavior for the resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by three separate incidents involving medication administration errors. In one instance, a registered nurse administered a multi-vitamin tablet without minerals to a resident, despite the physician's order specifying a multi-vitamin with minerals. The nurse later discovered the correct medication in the medication cart but had not noticed it earlier due to similar packaging. In another case, a licensed vocational nurse did not administer a prescribed chlorhexidine gluconate solution for oral care to a resident during the morning medication pass, only preparing it after the omission was identified during review. Additionally, a licensed vocational nurse failed to obtain a resident's blood sugar at the ordered time of 7 a.m., instead performing the test later in the morning and administering insulin based on the delayed reading. The nurse acknowledged missing the scheduled time and was unaware of the resident's insulin order for that morning. The facility's policy requires medications to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Expired Medications Found in Medication Cart
Penalty
Summary
Surveyors observed that two expired medications, a bottle of Rocklatan eye drops and a vial of Humalog insulin, were found stored in a medication cart during an audit conducted with a registered nurse. The medications had expiration dates of 4/7/25 and 4/8/25, respectively, and were still accessible for use. The registered nurse confirmed the medications were expired and explained that she was not the regular nurse for that medication cart, but was assisting with medication administration at the time. Review of the facility's policy indicated that outdated medications should be returned or destroyed per pharmacy instructions, but these expired medications remained in the cart.
Failure to Employ Qualified Dietary Services Manager in Absence of Full-Time RD
Penalty
Summary
The facility failed to employ a qualified Dietary Services Manager (DSM) in the absence of a full-time Registered Dietitian (RD) for 64 residents who received food from the kitchen. During a kitchen tour, surveyors observed improper food preparation, improper storage of food items, and unmaintained kitchen equipment. The Dietary Service Supervisor (DSS) confirmed she was not a certified Dietary Manager, having taken but not completed the required course. The RD, who was only present part-time, also confirmed the absence of a qualified Dietary Manager. The Nutrition Support Specialist (NSS), who covered the kitchen when the RD was not present, had not passed the exam to be a qualified RD. Interviews with facility staff, including the Administrator, confirmed that the RD worked only two to three days per week, and the NSS, who was not qualified as a RD, was responsible for overseeing the kitchen and staff during the RD's absence. Review of the facility's contract showed the RD was contracted for only 16 hours per week. The facility did not have a full-time qualified DSM as required by state regulations when the RD was not present, and the DSS did not meet the necessary certification or training requirements to supervise dietary services.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and service practices. A staff member was seen preparing food in the emergency three-compartment sink, which is not permitted for food preparation due to the risk of cross-contamination. Open packages of pasta were not stored in airtight containers, and several produce items, including cherry tomatoes, bell peppers, and strawberries, were found to be spoiled, mushy, or showing signs of mold and discoloration. Some of these items were not labeled or dated, making it unclear when they should be used or discarded. Additionally, a dented can of sweet potatoes was stored alongside ready-to-use canned goods, contrary to facility policy requiring damaged cans to be set aside for return or disposal. The mounted can opener was found to have a reddish and brown flaky coating near the blade, which was identified as rust. This equipment was not properly cleaned and sanitized, posing a risk of contamination to food prepared with it. Interviews with the Dietary Service Supervisor and Registered Dietician confirmed that staff were accustomed to using the three-compartment sink for food preparation and that there was a need for retraining. Facility policies and procedures reviewed by surveyors clearly stated that food preparation should not occur in these sinks, that opened dry goods should be stored in airtight containers, and that equipment must be cleaned and sanitized to prevent foodborne illness. The observed practices were not in compliance with these policies.
Improper Use of Hoyer Lift Without Required Staff Assistance
Penalty
Summary
A certified nursing assistant (CNA) transferred a resident from bed to wheelchair using a Hoyer lift without the required assistance of a second staff member. The resident had a history of muscle weakness, traumatic brain injury, and severely impaired cognition, and was documented as dependent on two or more helpers for transfers. The CNA acknowledged operating the Hoyer lift alone, stating it was a mistake and recognizing the risk of dropping the resident without support from another staff member. The resident's care plan indicated a self-care performance deficit, impaired balance, and dependence on staff for transfers. The facility's policy and procedure, as confirmed by the Director of Nursing (DON), required at least two nursing assistants to safely transfer a resident using a mechanical lift. The DON also confirmed that transferring the resident alone increased the risk for falls. The deficiency was identified through observation, interview, and record review.
Failure to Address Poor Food and Fluid Intake Resulting in Resident Dehydration
Penalty
Summary
A resident with multiple diagnoses, including Alzheimer's disease, severe protein-calorie malnutrition, and pressure injuries, was admitted to the facility and assessed as having severely impaired cognitive skills. The resident's care plan included a goal to consume more than 75% of meals to promote wound healing and prevent further skin breakdown. However, meal intake records over several days showed the resident consistently refused meals or consumed only 0–50% of food offered, with several instances of complete refusal. Fluid intake records also indicated the resident was consuming significantly less than the recommended daily amount, with daily totals ranging from 180 ml to 920 ml, well below the dietician's recommendation of 1,830–2,140 ml per day. Despite these ongoing issues, there was no timely intervention or escalation by staff. Certified Nurse Assistants (CNAs) observed and reported the resident's poor intake, but licensed nurses did not notify the Registered Dietician (RD) or the physician as required by facility policy. The RD confirmed she was not informed of the resident's recent poor intake and was unaware of the refusals to eat or drink. The Director of Nursing (DON) also acknowledged that no interventions were documented by licensed nurses to address the resident's poor intake, and the responsible party was not notified until several days after the issue began. Laboratory results revealed the resident was severely dehydrated, with elevated blood urea nitrogen, creatinine, and sodium levels. The facility's policies required prompt reporting and multidisciplinary assessment of poor intake and changes in condition, but these procedures were not followed. The lack of timely notification and intervention resulted in the resident developing dehydration and placed the resident at risk for malnutrition and further health decline.
Failure to Ensure Nursing Staff Competency and Infection Control Practices
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a registered nurse (RN), had the appropriate competencies and skills to provide safe and effective care for residents, as evidenced by the lack of completion of an annual competency and skills evaluation for the RN. This deficiency was observed in the context of infection control practices and the management of residents with complex medical needs. For example, one resident was admitted with enterocolitis due to a Clostridium difficile (C. diff) infection, requiring contact precautions. Observations revealed that the contact precaution signage was not properly displayed, and the RN used Clorox wipes with a white top, which were bleach-free, to disinfect medical devices, despite the need for sporicidal agents effective against C. diff. The Director of Nursing (DON) was unsure about the disinfectant's contents, and the Infection Preventionist (IP) clarified that only certain wipes were effective against C. diff spores. Additionally, another resident with a history of urinary tract infections experienced multiple episodes of diarrhea, which were not appropriately communicated or acted upon by the RN, despite being informed by a certified nursing assistant (CNA). The RN minimized the significance of the diarrhea, and there was no evidence of appropriate diagnostic testing or escalation. Review of facility policies indicated that staff should receive ongoing training in infection control and antibiotic stewardship, but the RN in question had not completed the required annual skills check. The DON acknowledged that failure to evaluate licensed nurses' skills could lead to significant errors.
Failure to Use Appropriate Disinfectants for C. diff Infection Control
Penalty
Summary
The facility failed to follow proper infection prevention and control procedures for a resident admitted with enterocolitis due to Clostridium difficile (C. diff) infection. Housekeeping staff did not use the appropriate disinfectant for cleaning the resident's contact precaution room. Instead of using the Sani-Cloth Germicidal Disposable Wipe/Bleach, which is effective against C. diff spores, the Housekeeping Aide used pink Ecolab Smartpower Sink and Surface sanitizer and purple Oasis 499 Disinfectant Cleaner, neither of which are indicated as effective against C. diff. The Sani-Cloth disinfecting wipes were not available on the housekeeping cart, and the Housekeeping Aide confirmed she only used the spray solutions and not the recommended wipes. Additionally, a Registered Nurse did not consistently use the appropriate disinfectant for medical devices between resident use. The nurse reported using Clorox wipes with a white top, which were found to be bleach-free, rather than a bleach-based disinfectant as required for C. diff precautions. The facility's policy specifies that environmental cleaning in rooms of residents with C. diff should be done with an EPA-registered germicidal agent effective against C. diff spores, such as bleach-based products. Observations and interviews confirmed that the recommended disinfecting agents were not used as per policy.
Failure to Implement Effective Antibiotic Stewardship and Monitor for Side Effects
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program, specifically lacking an adequate antibiotic stewardship program. A resident was administered Cephalexin for a personal history of urinary tract infections without documented evidence of a current infection, such as a urinalysis or urine culture. The clinical record did not indicate that appropriate diagnostic criteria, such as those outlined in the McGeer Criteria, were met prior to initiating antibiotic therapy. The resident experienced multiple episodes of diarrhea over several days, as documented by both certified nursing assistants and bowel and bladder elimination records. Despite these symptoms, there was no evidence that the resident was monitored for possible antibiotic side effects, nor was there documentation of appropriate follow-up or testing, such as sending a stool specimen for evaluation. Nursing staff were not consistently aware of the resident's symptoms, and discrepancies existed between CNA documentation and skilled nursing evaluations regarding the presence of diarrhea. Interviews with facility staff, including the Infection Preventionist, revealed concerns about the use of antibiotics as prophylaxis and the lack of adherence to established criteria for diagnosing urinary tract infections. The facility's policy required education on the relationship between antibiotic use and gastrointestinal disorders, but there was no indication that this was effectively implemented. The failure to monitor for side effects and to ensure antibiotics were prescribed only when clinically indicated contributed to the identified deficiency.
Insufficient Square Footage Provided in Multi-Bed Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 12 multi-bed rooms occupied by 31 residents. Measurements of the rooms showed that each resident had between approximately 70 and 73 square feet, which is below the regulatory standard. Multiple rooms were observed to have either two or three residents, and the square footage per resident was consistently less than required. These findings were based on direct measurements and observations conducted over several days. During the survey, residents and staff were interviewed and observed. One resident expressed that the room felt small and preferred a two-bed room, while another resident reported no complaints and was able to move around the room with a walker without difficulty. Observations of care provision indicated that there was sufficient space for routine care, and no negative consequences or safety concerns were identified as a result of the decreased space. The facility administrator requested a continuous room waiver for the affected rooms.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Treatment Nurse 1 (TN 1) during a wound dressing change for a resident with a Stage III pressure ulcer. TN 1 did not perform hand hygiene between glove changes while attending to the resident's wound care. Specifically, after cleansing the wound with normal saline and removing the soiled gloves, TN 1 donned a new pair of gloves to apply Santyl without washing hands. This process was repeated when TN 1 covered the wound with Mepilex dressing, again changing gloves without performing hand hygiene. The resident involved had been readmitted to the facility with a diagnosis of diabetes mellitus and had a treatment order for a sacral region pressure ulcer. The Director of Nursing confirmed that the failure to perform hand hygiene between glove changes increases the risk of infection. The facility's policy on hand hygiene, revised in August 2019, emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, stating that handwashing should occur after removing gloves and before handling clean or soiled dressings.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for two residents, leading to potential health risks. Resident 2, who was admitted with moderate protein-calorie malnutrition, had a chipped tooth that was not promptly referred for dental services within the required three days. Despite a physician's order for a dental consult dated 5/11/23, the referral was delayed until 6/6/24, 16 days after the issue was known. The resident reported difficulty eating due to the chipped tooth, which was part of their lower dentures, and expressed that the situation should have been treated as an emergency. Resident 3, admitted with dysphagia following a stroke and major depressive disorder, experienced a significant delay in obtaining replacement dentures after losing their full set. Although a dental consult was ordered on 10/19/23, the process to replace the dentures did not begin until 2/6/24, when dental impressions were taken. The delay in receiving the new dentures, which were ready by 7/9/24 but not fitted due to COVID, was attributed to the dentist's infrequent visits to the facility. The resident expressed feelings of depression and frustration due to the slow process. The facility's policy and procedure for dental services, last revised in December 2016, requires referrals for damaged or lost dentures to be made within three days, with documentation provided if there is a delay. However, this policy was not followed in the cases of Residents 2 and 3, leading to potential decreased food intake and significant weight loss. The Social Services Assistant was unaware of the three-day referral requirement, contributing to the delay in addressing the residents' dental needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that Resident 1 was free from physical abuse when Resident 2 repeatedly hit Resident 1 on the left lower extremity. Resident 1, who has Alzheimer's dementia, severe open-angle glaucoma, and type 2 diabetes mellitus, was admitted to the facility in March 2021. Resident 1's Minimum Data Set (MDS) indicated impaired vision and a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognitive response. On 2/14/24, Certified Nursing Assistant (CNA) 1 witnessed Resident 2 hitting Resident 1 on both legs. Resident 2, who has an intact cognitive response with a BIMS score of 15, stated that he was bothered by Resident 1's constant calls. Resident 1 reported feeling unsafe in the same room with Resident 2 unless staff was present. Resident 2's clinical record revealed a history of aggressive behavior, including an incident on 11/20/23 where Resident 2 was witnessed hitting another roommate and causing skin tears. On 2/14/24, CNA 1 responded to a call light in Resident 1 and Resident 2's room and found Resident 2 hitting Resident 1's legs with a closed fist. Resident 2 was separated from Resident 1, but this was not the first incident involving Resident 2's aggressive behavior. The facility's failure to protect Resident 1 from physical abuse by Resident 2 had the potential to result in physical injury and psychosocial harm.
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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) |
|---|---|---|---|---|
| Richmond Post Acute Care | 1.5 mi | ★★★★★ | 0 | 0 |
| Vale Healthcare Center | 2.2 mi | ★★★★★ | 5 | 0 |
| Creekside Healthcare Center | 2.3 mi | ★★★★★ | 3 | 0 |
| San Pablo Healthcare & Wellness Center | 2.3 mi | ★★★★★ | 5 | 0 |
| Shields Nursing Center | 3.2 mi | ★★★★★ | 3 | 0 |
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