Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Springs Of Richmond, The during CMS and state inspections, most recent first.
Wound Care Orders Not Timely Implemented and Admission Skin Assessment Incomplete: A resident with severe sacral and ischial pressure injuries had delayed and inconsistent wound care, including missed or discontinued NPWT, incomplete dressings, improper NPWT application, and prolonged use of an inadequate foam wheelchair cushion despite wound care instructions for an air-filled cushion. The resident’s sacral wound worsened with tunneling, bone exposure, and deterioration noted by the wound center. A second resident’s admission skin assessment was also incomplete, with multiple wounds documented but no thorough staging or wound description recorded.
Delayed Response to Resident Call Lights: Multiple residents reported that call lights were not answered in a timely manner, with waits of 20 to 30 minutes and, at times, no response at all. Residents described delays with toileting assistance, including during mealtimes and overnight, and one confidential interview reported the resident had to lie in urine for long periods. Resident Council records also documented ongoing concerns about call light response times, while the ED stated the facility had no way to track response times.
Failure to provide nail care and timely incontinence care: A resident with CVA and hemiparesis repeatedly had long fingernails after staff did not trim them as requested, another resident with CHF and severe cognitive impairment had long, dirty, jagged nails that remained untrimmed across multiple observations, and a third resident with bowel and bladder incontinence reported waiting up to 30 minutes or more for help after using the call light. The incontinent resident was observed yelling for help, had red, raw, excoriated skin in the perineal area, and a family member reported staff often turned off the call light and did not return.
Failure to arrange recommended optometry follow-up for a resident with retinal vascular changes and corrective lens needs. The resident was observed struggling to read with her glasses and stated she needed different glasses so she could read. The record showed the optometrist had ordered follow-up testing and exams, but the appointments were not completed in the expected time frames, and SSD and DOHS stated nursing was responsible for scheduling the eye doctor visits.
A resident with diarrhea, urinary incontinence, and skin irritation did not receive ordered PRN Imodium while having frequent loose stools, and the MAR showed no doses were given despite ongoing symptoms and documented MASD. Another resident reported new urinary urgency and frequency, but staff did not document an assessment or urinalysis after the change in condition, even though the resident had a history of UTI and an order to dip urine for UTI signs and symptoms.
Surveyors found that the facility failed to ensure bedside fluids for three residents who were care planned as at risk for dehydration. A resident with stroke, CKD, and UTI, and another with CHF and anemia, both cognitively intact, reported that fluids were only provided with meal trays or that they sometimes had to ask for water, with observations showing minimal or delayed water provision. A third, moderately cognitively impaired resident with severe sepsis, septic shock, and acute respiratory failure was repeatedly observed with an empty, undated Styrofoam cup and stated she always had to request water and that water had not been passed with her lunch. The Administrator reported there was no hydration policy and that water cups were only passed once per shift.
A resident, cognitively intact per MDS, developed a large, worsening bruise on the back that was documented in progress notes and led to an internal event and NP notification, but there was no documentation that the responsible party was informed. The family only became aware of the bruise and the resident’s report of a prior fall during a transfer when the resident was later hospitalized. This failure to notify occurred despite a facility policy requiring immediate notification of the responsible party for changes in condition.
A resident with a history of stroke was admitted from the hospital with a large traumatic wound on the right side of the back, described as purple, red, and erythematous. Facility documentation later noted that dark areas on the back were worsening, darkening, and increasing in size, and an internal event was opened and an NP notified, but no further assessments of the back or bruise were documented in the wound management record. The DON explained that events in the EHR became internal incident reports, yet no additional assessment notes were available despite a bruising policy requiring a bruise incident and assessment progress note. The resident reported having fallen during a staff-assisted transfer and hitting the bed, and the family stated they were not informed of either the large bruise or the fall.
A resident with multiple chronic conditions was given another resident's medications in error and later transferred to a hospital. The facility did not inform the hospital of the medication error at the time of transfer, and the hospital only learned of the incident after the resident's family provided the information. Staff interviews confirmed the expectation to report such errors, but no policy existed to guide this process.
A resident with complex medical needs, including end-stage renal disease and a history of medication allergies, was given another resident's morning medications in error. The resident did not receive their own prescribed medications, and the error was confirmed by staff and family interviews. The facility's medication administration policy, which requires verification of the five rights and resident identification, was not followed, leading to the error.
A resident with cancer and cognitive impairment did not receive timely follow-up after a hemolyzed CBC sample was reported, resulting in a missed critical lab value and subsequent hospitalization for acute on chronic anemia requiring transfusions. The facility lacked documentation of redraw or provider notification, and staff interviews revealed no clear policy for handling hemolyzed labs.
Two residents experienced significant delays in call light response, with one waiting up to 45 minutes and another waiting over two hours for assistance, leading to discomfort and feelings of helplessness. A staff member confirmed that inadequate staffing contributed to the inability to provide timely care and respond to residents' needs, resulting in a failure to promote resident dignity.
A resident with a knee infection was allowed to self-administer home medications, including narcotics, after admission when the facility did not have the prescribed drugs available. Nursing staff witnessed the resident and his son handling and taking medications from an unlabeled container, but did not complete the required self-administration assessment or obtain a physician order, contrary to facility policy.
A resident with multiple medical conditions did not receive her scheduled morning medications, including antihypertensives and other critical prescriptions, because she was marked as unavailable. The missed administration was not identified or reported by staff until several days later, and appropriate notifications to supervisors and providers were not made at the time.
A resident with a left knee infection was reported by multiple staff to have exhibited verbally aggressive behaviors and refused care, including wound dressing changes and urinal emptying. Despite these incidents, the medical record did not reflect any documentation of the refusals or behaviors, and staff confirmed there was no specific policy for documenting such events, resulting in incomplete medical records.
A facility failed to assess a resident's ability to self-administer a nebulizer medication. An LPN allowed the resident, who had a right arm sling due to a humerus fracture, to self-administer the nebulizer without documented assessment or care plan. The facility's policy required an assessment and return demonstration, which was not documented.
A facility failed to provide a homelike environment for a resident with acute respiratory disease, heart failure, and obesity. Observations revealed that the corner molding in the resident's room was detached, exposing drywall, and there were areas with missing paint. The Executive Director was unaware of these issues, which were attributed to the resident's use of a motorized wheelchair. The facility's expectation was to ensure a safe, clean, and homelike environment for all residents.
A facility failed to document and follow up on a resident's bowel movements, leading to inadequate constipation management. The resident, who was cognitively intact and continent, went 13 days without a bowel movement after admission. The facility lacked a policy for monitoring bowel movements, resulting in multiple undocumented periods of constipation.
A facility failed to administer g-tube feeding and water flushes as ordered for a resident with severe sepsis and dysphagia. The resident's feeding pump was observed running at outdated settings due to a communication lapse by the ADHS, who did not ensure nursing staff were informed of the updated physician's orders. This failure was contrary to the facility's policy requiring regular assessment and monitoring by a Registered Dietitian.
A facility failed to date oxygen tubing for a resident with acute kidney failure and falls, who required continuous oxygen. Observations over several days showed the tubing was not dated, contrary to the facility's policy. The ADHS noted that dates rubbed off, and labels were ordered to resolve the issue.
A resident with chronic pain conditions did not receive effective pain management despite reporting moderate pain. An LPN failed to administer or offer pain relief after the resident reported a pain level of 5 out of 10. The facility's policy on pain management was not followed, as no follow-up or documentation was completed.
The facility failed to administer medications as ordered for three residents, leading to deficiencies in pharmaceutical services. A resident with a UTI received an antibiotic for longer than prescribed, another resident did not receive several medications during a respite stay, and a third resident was given a higher dose of Ambien than ordered. The facility did not notify physicians or the pharmacy about these discrepancies.
The facility failed to provide a clinical rationale for denying a gradual dose reduction of antidepressant and antianxiety medications for two residents. One resident, with no documented anxious behaviors, was prescribed clonazepam, and despite recommendations for dose reduction, the physician denied changes without initial rationale. Another resident, receiving two antidepressants, had dose reduction evaluations denied without specific justification until later documentation cited severe depression. The facility's policy requires documented medical necessity for psychotropic medications, which was not initially met.
A facility failed to follow Enhanced Barrier Precautions (EBP) during care for a resident with a feeding tube. Despite a sign indicating the need for gloves and gowns during high-contact activities, two CRCAs provided perineal care without gowns. The Director of Health Services acknowledged the oversight, which violated the facility's infection control policy.
A resident with a pressure ulcer did not receive consistent wound assessments and documentation as required. The wound nurse failed to enter handwritten notes into the EHR, and the attending physician was not informed of the ulcer until weeks later. The care plan included weekly assessments, but these were not consistently documented, and discrepancies were found in the records of dressing changes and wound assessments.
The facility failed to document meal intakes for three residents with nutritional concerns, leading to a deficiency. A resident with multiple health issues had difficulty chewing and inconsistent meal documentation. Another resident with a history of rhabdomyolysis and heart conditions had missing meal records despite weight monitoring. A third resident with malnutrition and pressure ulcers also had incomplete meal documentation, despite interventions. The facility's policy required meal intakes to be recorded, which was not consistently followed.
Wound Care Orders Not Timely Implemented and Admission Skin Assessment Incomplete
Penalty
Summary
The facility failed to timely implement wound care orders and interventions for a resident with severe pressure injuries, and the resident’s sacral wound deteriorated during the course of care. Resident 6 was admitted with a sacral pressure wound and a pressure area to the ischium, was cognitively intact, and required substantial to maximum assistance with repositioning, toileting, showering, and locomotion. The resident’s wound care plan included pressure-reducing devices, treatment per MD order, and notification of the MD if treatment was not effective. The record also showed orders for negative pressure wound therapy, wet-to-moist dressings when needed, and a pressure-reducing wheelchair cushion. The wound record and interviews showed repeated problems with the wound vac and dressing management. The treatment record showed a scheduled negative pressure dressing change on 1/12/2026 was left blank, and on 1/21/2026 the negative pressure therapy was documented as discontinued. Wound center notes described the sacral wound as progressively larger and deeper, with tunneling, slough, and later bone involvement. On 1/22/2026, the wound center documented that the dressing in place covered only part of the wound, that the wound vac had stopped working and been removed after at least 24 hours, and that there was now exposed bone and a new deep tissue injury of intact skin. Later wound center notes stated the wound vac was applied inappropriately, including the bulb being placed directly over bone instead of bridged, and the exposed bone had deteriorated. The record also showed that the resident was transported and cared for on an inadequate wheelchair cushion despite repeated wound care instructions for a ROHO or equivalent air-filled cushion and no foam cushions. Facility staff and the ADNS acknowledged the resident remained on a foam cushion for weeks before an air-filled cushion was delivered, and wound center providers repeatedly documented that the cushion was inadequate. Staff interviews also showed inconsistent wound care practices, including wet-to-moist dressings being used when the wound vac was not reapplied, uncertainty about whether the physician or wound care had been notified, and the resident being sent to wound care on foam cushions. In addition, for Resident 2, the admission skin assessment was not thoroughly completed: the admission nursing note and wound management assessment documented multiple buttock and heel wounds, but the ADON stated the admitting nurse could not assess staging because she was an LPN, there was no depth listed for the wound on admission, and the buttock wounds lacked a full description. The facility policy required detailed documentation of wound characteristics when skin alterations were noted on admission.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered timely for 5 of 6 residents reviewed for accommodations of needs, including Residents 92, 6, 61, 55, and 26. During a Resident Council interview, Residents 61, 55, and 26 stated they were unable to get their call lights answered for assistance and that staff sometimes took 20 to 30 minutes to respond. Resident Council meeting records from October 2025, November 2025, December 2025, and February 2026 also showed ongoing resident concerns about call lights not being answered in a timely manner. Resident 92 stated he had to wait for toileting assistance and that his call light could take up to 30 minutes to be answered, especially during mealtimes. Resident 6 stated call lights could take up to 30 minutes to be answered and that staff would sometimes come in, turn the light off, and not return. A confidential interview indicated call lights had been timed at up to 30 minutes to answer and sometimes were not answered at all during the night, with the resident having to lie in urine for long periods of time. The ED stated call lights should be answered as soon as possible but the facility did not have a way to track response times, and the Activity Director stated call light wait times had been a concern in Resident Council.
Failure to Provide Nail Care and Timely Incontinence Care
Penalty
Summary
The facility failed to provide dependent residents with nail care and failed to provide timely incontinent care for 3 of 3 residents reviewed for ADL care. One resident with a CVA and left-sided hemiparesis was observed with long fingernails on multiple occasions, and the resident stated staff had not assisted with trimming them. The resident reported asking CRCA 1 and CRCA 6 to trim the nails, but they never came, and said the nails had been long since admission. The resident also stated he was afraid he would scratch himself because of the length of the nails. The care plan for this resident included providing nail care on shower days and as needed. A second resident with CHF and severe cognitive impairment required partial/moderate assistance with personal hygiene. During repeated observations, the resident’s fingernails were long, dirty, and had jagged, sharp edges on both thumbs and both middle fingers. The resident stated the nails needed to be trimmed and later said no staff had gotten around to trimming them yet. The DHS stated residents should be offered nail care and trimming on shower days and that nursing was responsible for ensuring nail care was provided. A third resident with spinal stenosis, muscle weakness, diarrhea, and urinary incontinence was documented as incontinent of bowel and bladder and needing toileting and incontinence care as needed. The resident stated they could lie in bed soiled for up to a half hour waiting for help, and later reported that after pushing the call light for incontinence care, staff said they would get someone and never returned, forcing the resident to yell for help after waiting over thirty minutes. The resident was observed yelling for help with the call light on, and later was found with the vaginal area red, raw, and excoriated from the vaginal area up to the buttocks, with moaning during cleaning. The resident’s family member also reported that nearly every day the resident needed help getting cleaned up and staff would turn off the call light and not return.
Failure to Arrange Recommended Optometry Follow-Up
Penalty
Summary
The facility failed to set up follow-up appointments with the optometrist as recommended for Resident 51, who had a diagnosis that included bilateral changes in retinal vascular appearance. During an observation and interview, the resident was holding a book and moving her glasses around to read it, stating that she had not had her glasses very long but needed to move them to see well enough to read. The resident said she preferred reading over watching television, had several books and magazines on her nightstand, and wanted different glasses so she could see to read. The clinical record showed that the resident was cognitively intact and required corrective lenses for vision. The optometrist had recommended follow-up in 1 to 3 months after an ERG and later after a dilated fundus exam, but the resident did not have those appointments or tests completed in the expected time frames. During interviews, the SSD and DOHS stated that nursing was responsible for scheduling the follow-up eye doctor appointments, and the facility did not have a policy for ancillary services.
Failure to Provide PRN Diarrhea Medication and Assess New Urinary Symptoms
Penalty
Summary
The facility failed to provide prescribed PRN Imodium to a resident with diverticulosis, diarrhea, urinary incontinence, and weakness in both lower extremities when the resident was having frequent loose stools. The resident’s record showed an order for Imodium A-D 2 mg PRN for diarrhea, later changed to a scheduled three-times-daily order, but the February MAR showed no PRN Imodium was administered after the order was received. Progress notes documented frequent soft/loose stools, buttock pain, redness and shearing at the coccyx, and moisture-associated skin damage to the groin area. The resident stated that no one had offered Imodium when diarrhea was occurring and that the first dose received in the last couple of days had helped a lot. The facility also failed to assess a resident who reported a sudden increase in urinary frequency and urgency. The resident stated that for the prior 3 to 4 days she had been running to the bathroom constantly, sometimes could urinate and sometimes could not, and felt she needed a bedside commode because she was going almost every 10 minutes. A QMA reported the resident’s complaint to an LPN, but there was no documentation of an assessment, no documented change in condition related to urination, and no urinalysis completed on that day. The LPN indicated an event should have been opened for the new urgency symptoms and that nursing staff would follow up for 72 hours, but no event was started. The resident’s record showed a history of UTI, an order allowing staff to dip urine for signs and symptoms of UTI, and a care plan identifying the resident as at risk for UTI and to observe continence status and report changes as needed. The admission MDS indicated the resident required supervision for ambulation and toileting and was occasionally incontinent of urine. The DNS stated she would expect the LPN to follow up after the QMA reported the resident’s urinary concerns.
Failure to Ensure Bedside Hydration for Residents at Risk of Dehydration
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate residents’ hydration needs and preferences by not ensuring fluids were available at bedside for three residents assessed as at risk for dehydration. One resident with diagnoses including stroke, chronic kidney disease, and UTI, and care plans identifying risk for dehydration, diuretic use, and constipation with interventions to encourage and offer fluids, reported only receiving fluids with meal trays. The resident’s family member, who visited daily, stated the resident never had fluids in the room and that the family had to provide fluids every day. Another resident, cognitively intact with diagnoses including CHF and iron deficiency anemia and a care plan indicating risk for dehydration with an intervention to offer fluids, was observed in the morning with a Styrofoam cup containing only a small amount of water and reported that no water had been brought that day and that sometimes he had to ask for it. Later that day, he reported receiving fresh water for the first time about twenty minutes prior. A third resident, moderately cognitively impaired with diagnoses including severe sepsis with septic shock and acute respiratory failure with hypoxia, and care planned as at risk for dehydration with an intervention to offer fluids, was twice observed with an empty Styrofoam cup without a date, first stating she always had to ask for water and later indicating the empty cup with ice came on her lunch tray and that water had still not been passed. The Administrator stated there was no facility hydration policy and that water cups were passed once per shift.
Failure to Notify Family of Resident’s Significant Bruising and Possible Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family of a significant change in condition, specifically the development and worsening of a large bruised area on the resident’s back. A family member reported that they first observed the large bruise when the resident was admitted to the hospital on 12/21/25 and stated they had not been informed of the bruise or of any fall. The resident told the family member that about a week prior to the hospital admission, she had a fall during a transfer with staff. Review of the clinical record showed no documentation that the resident had a fall. The resident’s admission MDS, dated 9/24/25, indicated the resident was cognitively intact and able to make consistent and reasonable daily decisions. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and had increased in size. An event was opened to ensure the wound nurse was aware, and the Nurse Practitioner was notified. However, the documentation did not show that the resident’s family had been notified of this change in condition. During an interview, the DNS explained that when an event was created in the computer, it was turned into an internal incident report, and no further information or documentation of family notification was provided. The facility’s notification policy stated that the resident’s responsible party would be notified immediately of a change in condition, but this was not reflected in the record for this resident.
Failure to Assess and Document Large Back Bruise and Notify Family
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough and accurate assessment of a large bruised area on a resident’s back and to document ongoing evaluation of the condition. Hospital documentation dated 1/21/26 indicated that the resident had a traumatic wound on admission to the right side of the back measuring 22 cm by 9 cm, described as purple and red with erythema. The resident’s diagnoses included stroke, and the clinical record did not indicate that the resident had a fall. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and increasing in size, and that an event was opened to ensure the wound nurse was aware and the Nurse Practitioner was notified. However, there were no further assessments of the back area documented after this note. Review of the wound management record on 1/28/26 showed no bruising assessment for the resident’s back or any other assessment of the back. During interview, the DNS stated that when an event was created in the computer it was turned into an internal incident report, and no additional documentation or assessments were provided to surveyors. The facility’s bruising policy required completion of a bruise incident in the electronic health record along with a template/assessment progress note, but such documentation was not present. In addition, during an interview, the resident’s family member reported they were not notified of a large bruise on the resident’s back. The resident reported having had a fall during a transfer with staff and hitting the side of the bed, and the family member was not aware of either the fall or the bruising.
Failure to Notify Hospital of Medication Error During Resident Transfer
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, dependence on renal dialysis, and pulmonary edema, received another resident's morning medications in error. The incident was immediately reported to the nursing supervisor, Director of Health Services (DHS), and Nurse Practitioner (NP), who assessed the resident and implemented orders to monitor for potential side effects. The resident was made aware of the error, and an attempt was made to notify his wife. The resident was subsequently transferred to a local hospital. Upon transfer, the facility failed to notify the receiving hospital that the resident had received the wrong medications prior to admission. There was no documentation provided to the hospital regarding the medication error, and the hospital only became aware of the incident after the resident's family member obtained and delivered the information. Interviews with facility staff confirmed that it was expected for the nurse transferring the resident to report such incidents, but there was no policy in place outlining what should be communicated to the hospital during transfers.
Resident Received Another Resident's Medications Due to Medication Administration Error
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, and dependence on renal dialysis, was administered another resident's morning medications in error. The resident's care plan included interventions to administer medications as ordered, and the resident was identified as being at risk for dehydration, fluid imbalance, and pain related to several chronic conditions. On the day of the incident, the resident did not receive their scheduled morning medications and instead received a full set of medications intended for another resident. The medications administered in error included several drugs with significant potential side effects, such as amlodipine, atorvastatin, duloxetine, Eliquis, furosemide, gabapentin, potassium chloride, sotalol, and atenolol. The resident had a documented allergy to atorvastatin, with previous reactions of dizziness and rash. At the time of the incident, the resident was assessed and found to have no immediate signs or symptoms of adverse effects, and no rash was present. The resident was later sent to the hospital due to symptomatic bradycardia and ongoing concerns related to his medical history, including orthostatic hypotension and dialysis needs. Interviews with facility staff, the resident's family member, and the nurse practitioner confirmed that the resident received the wrong medications and did not receive his own scheduled medications. The facility's medication administration policy required verification of the five rights of medication administration, including resident identification, but this process was not followed, resulting in the medication error.
Failure to Follow Up on Hemolyzed Lab Results Leads to Hospitalization
Penalty
Summary
The facility failed to timely follow up on hemolyzed laboratory results for a resident with a history of malignant melanoma and encephalopathy, who was at risk for complications related to cancer. The resident had physician orders for weekly complete blood count (CBC) tests, with results to be faxed to the oncologist. On one occasion, a CBC drawn was found to be hemolyzed and the laboratory requested a new order and recollection, but there was no documentation in the progress notes that the lab was redrawn or that the provider was notified. The resident's care plan included monitoring laboratory results as ordered, but this was not followed. Subsequently, several days later, the resident exhibited confusion and a new CBC was obtained, revealing a critically low hemoglobin level. The resident was then transferred to the emergency room and hospitalized for acute on chronic anemia, requiring multiple blood transfusions. Interviews with family and the oncologist's office confirmed that no CBC results were received during the period in question, and facility staff were unable to explain why the labs were not redrawn or the provider notified. There was no specific policy in place for handling hemolyzed samples.
Failure to Ensure Timely Call Light Response and Resident Dignity
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and timely assistance, as evidenced by prolonged call light response times for two residents. One resident, who was cognitively intact and had diagnoses including aftercare following joint replacement surgery and hypertensive heart disease, reported that call light response times varied from a few minutes to as long as 45 minutes, with waits usually exceeding 15 minutes. She expressed discomfort and distress due to the delays, particularly when needing immediate assistance to use the bathroom. The facility's policy required call lights to be answered as quickly as possible, but this standard was not met. Another resident, alert and oriented with a diagnosis of infection related to an internal prosthetic, reported waiting over two hours for assistance after initially requesting help, and an additional 45 minutes after a second request. This resident described feeling helpless due to the repeated and prolonged waits. A Certified Resident Care Associate confirmed that staffing levels were inadequate, often leaving her responsible for 37 patients and unable to provide routine care or respond to call lights promptly. She acknowledged that residents sometimes waited 30 minutes or more for assistance, especially when she required help from a nurse for certain residents, leaving no one available to respond to other needs.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with a medical history of a left knee infection related to an internal prosthetic was admitted to the facility and was alert and oriented upon admission. On the night of admission, the resident's son brought in home medications, including narcotics, because the facility did not have the resident's prescribed medications available. The resident and his son administered the medications, and the resident confirmed taking his own oxycodone. Nursing staff, including two LPNs, were aware that the resident was using medications brought from home, some of which were in an unlabeled container. One LPN attempted to verify the medications verbally with the resident but did not complete a self-administration of medication assessment and was unfamiliar with the facility's policy on self-administration. The other LPN, who admitted the resident, also did not complete the required assessment. Review of the clinical record revealed there was no documentation of a Self-Administration of Medication assessment or a physician order authorizing self-administration. Facility policy required an assessment to be completed for any resident requesting or engaging in self-administration of medication. The failure to assess the resident's ability to safely self-administer medications and to follow policy regarding verification and documentation led to the deficiency.
Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
A resident with diagnoses including aftercare following joint replacement surgery, cerebral ischemia, and hypertensive heart disease did not receive her prescribed morning medications on a specific date. The medications missed included antihypertensives, an antiplatelet, a supplement, an antidepressant, an antianginal, and an antidiabetic agent. The medication administration record indicated these medications were not administered because the resident was marked as unavailable. The resident later reported feeling dizzy that afternoon and realized she had not received her morning medications. She did not inform facility staff of the missed dose at the time. The facility only became aware of the missed medication administration several days later, on the resident's discharge date, when the issue was brought to their attention. The nurse responsible was a relatively new staff member and had not communicated any difficulties in locating the resident, despite being checked on multiple times by supervisory staff. Documentation showed that the nurse practitioner was informed of the missed dose, but no new orders were received. The facility's process for notifying supervisors, providers, and the resident or responsible party was not followed at the time of the incident.
Failure to Document Resident Refusals and Aggressive Behaviors
Penalty
Summary
The facility failed to accurately document the behaviors and refusals of care for a resident with a medical diagnosis of a left knee infection related to an internal prosthetic. The resident was alert and oriented upon admission. Multiple staff interviews revealed that the resident exhibited verbally aggressive behaviors, including cussing at staff, refusing care such as wound dressing changes and urinal emptying, and expressing intentions to leave the facility against medical advice. Staff described the resident as agitated, frustrated, and resistive to assistance, with specific incidents where the resident verbally abused staff and refused interventions. Despite these reported behaviors and refusals, a review of the resident's medical record showed no documentation of these events. The facility did not have a specific policy for documenting behaviors, but the expectation was that refusals of care would be recorded in the chart. The lack of documentation was confirmed during interviews with staff and the corporate nurse, indicating a failure to maintain accurate and complete medical records in accordance with accepted professional standards.
Failure to Assess Resident's Ability to Self-Administer Nebulizer
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed and deemed appropriate to self-administer a nebulizer medication. During an observation of medication administration, an LPN prepared and handed a nebulizer face mask to a resident who then self-administered the medication. The LPN left the room while the resident continued the nebulizer treatment. The resident had a sling on her right arm due to a humerus fracture, and the nebulizer machine was placed on the right side of her bed, which could have posed a challenge for her to manage the equipment safely. The resident's clinical record indicated a recent orthopedic appointment where she was advised to be non-weight bearing on her right upper extremity. Although the resident expressed a desire to self-administer medications, there was no documented assessment or care plan in the electronic health record to confirm her capability to safely self-administer the nebulizer treatment. The facility's policy required an assessment and return demonstration to ensure safety, which was not documented in this case.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 14, who was reviewed for homelike environment. The resident's clinical record indicated diagnoses including acute respiratory disease, heart failure, and obesity. During observations, it was noted that the corner molding in Resident 14's room was detached from the wall, exposing the drywall where it connected at the corner. The molding was found leaning against the opposite wall, and there were areas where paint was missing on the wall behind the head of the bed. These observations were made on multiple occasions. During a tour, the Executive Director stated he was unaware of the molding issue and missing paint, acknowledging that this had been a recurring problem due to the resident's use of a motorized wheelchair. The facility's expectation was to maintain a safe, clean, and homelike environment for all residents.
Failure to Document and Follow Up on Resident's Bowel Movements
Penalty
Summary
The facility failed to ensure proper documentation and follow-up for a resident's bowel movements, leading to a deficiency in care for constipation management. Resident G, who was cognitively intact and always continent of bowel, was admitted with a diagnosis that included constipation. Despite having a bowel and bladder care plan in place, which required notifying the charge nurse of changes in bowel patterns, the facility did not document or follow up on the resident's bowel movements adequately. The resident went 13 days without a bowel movement after admission, as reported by a family member. The electronic health record showed multiple instances where Resident G went several days without a documented bowel movement, including periods of up to six days without any record. The Executive Director confirmed that there was no facility policy regarding the monitoring of bowel movements. This lack of documentation and follow-up is contrary to the guidelines from the National Library of Medicine, which defines constipation as having three or fewer bowel movements per week.
Failure to Administer G-Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer gastric tube (g-tube) feeding and water flushes as ordered by the physician for Resident 299, who was reviewed for nutrition. Resident 299 had a medical history that included severe sepsis with septic shock, dysphagia, and was receiving orthopedic aftercare following surgical amputation. The care plan for tube feeding, initiated and revised in February 2025, required adherence to specific feeding and flushing orders. However, observations on two separate occasions revealed that the feeding pump was running at the previous order's settings, which had been discontinued, rather than the updated physician's orders. The discrepancy arose because the Assistant Director of Health Services (ADHS) entered the new order for the g-tube feedings and flushes but failed to ensure that the nursing staff was informed of the change. The Director of Health Services (DHS) confirmed this lapse in communication during an interview. The facility's policy on tube feedings, which was revised in May 2024, mandates that residents requiring tube feeding be assessed by a Registered Dietitian or Nutrition & Dietetics Technician, Registered, with monthly monitoring. This policy was not effectively followed, leading to the deficiency in care for Resident 299.
Failure to Date Oxygen Tubing for Resident
Penalty
Summary
The facility failed to properly date oxygen tubing for a resident requiring respiratory care. Resident 253, who has diagnoses including acute kidney failure and falls, was observed on multiple occasions with oxygen tubing that was not dated. A physician's order required the resident to be on continuous oxygen at two to three liters per minute. Observations on three separate days revealed that the oxygen tubing at the resident's bedside was not dated as per the facility's policy. The Assistant Director of Health Services acknowledged the issue, noting that the dates rubbed off the tubing, and indicated that labels had been ordered to address the problem. The facility's Administration of Oxygen Policy mandates that tubing be dated when initiated and changed monthly or as needed.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for Resident 251, who had diagnoses including Alzheimer's disease, chronic back pain, and chronic vertebral fractures due to osteoporosis. A physician's order required monitoring of the resident's pain three times a day for seventy-two hours, and a pain medication order allowed for morphine concentrate solution to be administered every four hours as needed. Despite the resident rating her pain as a 5 out of 10, indicating moderate pain, on 2/12/25, no pain medication was administered, and no follow-up was documented in the electronic health record (EHR). During an interview, an LPN admitted to not providing any pharmacological or non-pharmacological interventions after the resident reported her pain level. The LPN acknowledged forgetting to check if there was an order for pain medication. Additionally, the resident's daughter reported that the resident experienced discomfort during care activities. A progress note later indicated that the resident was resting without outward signs of pain, but the facility's policy required evaluation and documentation of pain management effectiveness, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for three residents, leading to deficiencies in pharmaceutical services. Resident G, diagnosed with sepsis and a urinary tract infection (UTI), was prescribed cefdinir 300 mg twice a day for seven days. However, the medication administration record (MAR) indicated that the antibiotic was administered for eight days on two separate occasions, contrary to the physician's orders. This discrepancy in medication administration was not addressed or corrected by the facility. Resident C, admitted for a respite stay, did not receive several medications as they were listed as unavailable in the MAR. These included Depakote, ropinirole, Rytary, and trazodone. There was no documentation indicating that the physician was notified of the missed doses or that the pharmacy was contacted to ensure medication delivery. Additionally, Resident 40, who had orders for Ambien 5 mg for insomnia, was incorrectly administered 10 mg on multiple occasions, as documented in the controlled drug use record. The Director of Health Services confirmed that medications should be administered as ordered, highlighting a failure in the facility's medication management processes.
Failure to Provide Rationale for Denial of Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure a clinical rationale was provided for the denial of a gradual dose reduction (GDR) of antidepressant and antianxiety medications for two residents. Resident 30, diagnosed with conditions including major depressive disorder and agoraphobia with panic disorder, was prescribed clonazepam. Despite a lack of documented anxious behaviors and multiple pharmacist recommendations for a GDR, the physician repeatedly denied the reduction without providing a specific rationale. It was only after a recent fall that the physician noted the resident's seizure disorder and risk of breakthrough seizures as reasons for maintaining the current dosage. Resident 26, who was cognitively intact and exhibited no behaviors, was receiving two antidepressants: venlafaxine and Wellbutrin. The facility's care plan required attempts at GDR unless clinically contraindicated. However, despite pharmacy recommendations for dose reduction evaluations, the physician denied changes without initially providing a specific rationale. It was later documented that the resident's severe depression related to recent illness and overall decline justified the continuation of the current dosages. The facility's policy on psychotropic medication usage and GDRs mandates that residents receive such medications only if medically necessary, with documented justification. The policy also requires ongoing efforts to reduce dosages unless contraindicated. In both cases, the facility did not initially provide adequate documentation or rationale for the continued use of the medications at their current dosages, leading to the identified deficiency.
Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices by not adhering to Enhanced Barrier Precautions (EBP) during the provision of activities of daily living (ADL) care for a resident. Resident 299, who had a history of severe sepsis with septic shock, dysphagia, and was receiving tube feeding, was observed in a room with a sign indicating the need for EBP. The sign instructed that gloves and gowns should be worn for high-contact care activities, such as providing hygiene and toileting assistance. However, during an observation, two Certified Resident Care Associates (CRCAs) were seen providing perineal care to the resident without wearing gowns, although gloves were used. A cart with the necessary personal protective equipment (PPE) was available in the room. The Director of Health Services confirmed that the CRCAs should have been wearing the appropriate PPE, as outlined in the facility's Enhanced Barrier Precautions Standard Operating Procedure. This policy mandates the use of gloves and gowns during high-contact care activities for residents with indwelling medical devices, such as feeding tubes, which was applicable to Resident 299. The failure to adhere to these precautions during the care of Resident 299 represents a deficiency in the facility's infection control practices.
Inadequate Wound Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure routine and timely wound assessments for a resident with a pressure ulcer. Resident B, who was admitted with an unstageable pressure ulcer, did not receive consistent weekly wound assessments and documentation as required. The initial wound assessment was incomplete, lacking details such as the stage of the wound, drainage, color, odor, wound margins, surrounding tissue, and presence of tunneling or undermining. The wound nurse admitted to not entering the handwritten notes into the electronic health record (EHR), and the attending physician was not informed of the pressure ulcer until several weeks after admission. The care plan for Resident B included weekly skin assessments and wound measurements, but these were not consistently documented. The wound nurse acknowledged being overwhelmed with responsibilities, which contributed to the lack of documentation. The facility's records showed discrepancies in the documentation of dressing changes and wound assessments, with only one dressing change recorded in the Treatment Administration Record (TAR) for May 2024, despite orders for daily changes. Additionally, the application of a foam dressing was not documented in the EHR. Interviews with facility staff revealed that the wound nurse did not document the application of a foam dressing or enter specific care orders into the EHR. The facility's policy required weekly documentation of wound measurements and conditions, but this was not adhered to until later in May 2024. The lack of consistent documentation and communication regarding Resident B's pressure ulcer care led to a deficiency in the facility's wound care practices.
Failure to Document Meal Intakes for Residents with Nutritional Concerns
Penalty
Summary
The facility failed to routinely document meal intakes for three residents with nutritional concerns, leading to a deficiency in maintaining adequate nutrition records. Resident B, who had multiple health issues including a heart attack, diabetes, and obesity, was noted to have difficulty chewing due to not wearing dentures. Despite a family member's request for a nutritionist, there was no follow-up, and meal intakes were not consistently documented. The Registered Dietitian (RD) recommended dietary supplements and monitoring, but several meals were not recorded, indicating a lapse in documentation. Resident C, with a history of rhabdomyolysis, sepsis, and heart conditions, was on a mechanical soft diet. The RD noted significant weight gain, which was considered beneficial, and planned to monitor weights and intakes. However, meal documentation was missing for several meals in June, indicating a failure to consistently record meal intakes as per the facility's policy. Resident D, who had malnutrition and pressure ulcers, was closely monitored by the RD due to significant weight loss. Despite interventions like a liberalized diet and nutritional supplements, meal intakes were not consistently documented. The RD noted a recent weight gain, but the lack of meal documentation on specific dates highlights a deficiency in maintaining accurate nutritional records. The facility's policy required meal intakes to be recorded in the electronic health record, which was not adhered to, leading to this deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 168 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows Of Richmond | 0.5 mi | ★★★★★ | 1 | 0 |
| Rosebud Village | 0.5 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare - Richmond Care Center | 2.5 mi | ★★★★★ | 14 | 0 |
| Forest Park Health Campus | 3.7 mi | ★★★★★ | 12 | 0 |
| Arbor Trace Health & Living Community | 4.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.