Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 New Richland Care Center during CMS and state inspections, most recent first.
The facility failed to provide physician-ordered dressing changes, assess wounds during dressing changes, monitor for signs of worsening infection, notify the physician of changes in condition, and ensure timely administration of antibiotics for three residents with complex wounds and infection risks. Staff did not consistently document wound care, communicate supply shortages, or recognize early signs of sepsis, resulting in missed treatments and inadequate monitoring.
The facility failed to develop a comprehensive QAPI plan, as the administrator and DON could not provide a written plan during a survey. Although they mentioned ongoing performance improvement projects, the absence of a formalized plan indicates a lack of structured guidance. The existing QAPI policy was inadequate, lacking details on feedback utilization, data monitoring, and systematic problem analysis.
The facility failed to conduct fit testing for N95 respirators as per CDC guidelines. Staff, including a housekeeping assistant and nursing assistants, were observed using N95 masks without fit testing. The infection preventionist confirmed that fit testing was not routinely conducted, and the director of nursing was unaware of the plan for PAPRs, which were not in use. The facility's policy referenced OSHA and CDC guidelines, but these were not followed.
A resident with a history of falls and moderate fall risk slid out of a power lift recliner due to the facility's failure to assess her ability to use the chair safely. The facility lacked policies on lift chairs, and no assessment was completed before the resident used the chair, despite staff acknowledging the need for such assessments.
The facility did not ensure that the most recent survey results were accessible to residents or visitors. A binder labeled 'Survey Results' near the entrance contained outdated results, and the latest federal recertification survey results were missing. The social services director confirmed the absence of current results, and the administrator was unaware of the issue. No policy on posting survey results was provided.
A resident with chronic right heart failure was not adequately monitored for fluid overload, and physician-prescribed daily weights were not consistently obtained or documented. Despite significant weight gain and observed edema, the facility failed to notify the physician of the resident's refusals to be weighed and did not have a protocol for such notifications. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition.
A facility's failure to implement a comprehensive system for pressure ulcer prevention and management led to a resident developing a stage 4 pressure ulcer, resulting in sepsis, osteomyelitis, and death. The facility did not conduct comprehensive assessments, failed to monitor wounds effectively, and did not involve physicians in a timely manner. The resident's care plan was not updated with necessary interventions, and wound care practices were inadequate, with treatments applied without physician orders and assessments lacking critical information.
The facility's QAPI/QAA program was ineffective in addressing impaired skin integrity and pressure injuries, as revealed by inadequate documentation and lack of comprehensive action plans during QA meetings. Despite ongoing skin issues, including one resulting in a resident's death, no new quality improvement projects were developed. Staff interviews highlighted a lack of awareness and training in wound care and pressure ulcer management.
The facility failed to notify physicians and family members of pressure injuries for four residents. One resident developed severe sepsis due to unreported wounds, while another had a pressure sore from shoes that went unreported for months. Two other residents had multiple pressure ulcers without physician notification. Staff interviews revealed confusion about notification processes and standing orders for wound care.
The facility failed to ensure that nursing staff were trained and competent in pressure ulcer assessment and management, potentially affecting all residents at risk for or with existing pressure ulcers. Interviews revealed that the infection preventionist/wound nurse (IPWN-A) and other LPNs lacked adequate wound care training. Despite the Director of Nursing and Administrator's belief that training had occurred, records showed only one training session from 2021 to 2024. Competencies and education records were not provided upon request.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper hand hygiene, leading to potential infection risks. Staff did not adhere to EBP protocols for residents with conditions like osteomyelitis and pressure ulcers, and vital sign equipment was not disinfected between uses. Hand hygiene was inadequate, with staff failing to sanitize hands before and after resident contact. Interviews revealed a lack of understanding and training on EBP and hygiene practices.
The facility failed to report allegations of abuse involving two residents to the State Agency as required by their policies. One resident reported being slapped by a nursing assistant, and another reported being yelled at due to incontinence issues. Despite being informed of these allegations, the facility did not report them, as confirmed by interviews with staff.
A resident with multiple diagnoses reported being yelled at by a nursing assistant due to incontinence, which upset him. The facility failed to conduct a thorough investigation as required by its policy, despite confirming the need for such an investigation. The nursing assistant's hours were reduced, and they were reassigned, but no comprehensive investigation was completed.
Failure to Provide Physician-Ordered Wound Care and Monitor for Infection
Penalty
Summary
The facility failed to provide physician-ordered dressing changes, assess wounds during dressing changes, monitor for signs and symptoms of worsening infection, notify the physician of changes in condition, and acquire necessary dressing change supplies for three residents. In one case, a resident with a history of chronic venous hypertension, severe sepsis, and multiple lower extremity ulcers did not receive daily dressing changes as ordered, and wound assessments were not completed with each dressing change. There were missed wound assessments and treatments on several dates, and staff did not notify the physician when the wound increased in size or when there were changes in wound characteristics such as increased drainage, odor, and pain. The resident experienced increased redness and pain, which was not promptly assessed or communicated to the physician, and antibiotics were not administered in a timely manner despite being available in the facility's emergency kit. Another resident with severe cognitive impairment, osteomyelitis, pressure ulcers, and on hospice care did not consistently receive dressing changes as ordered. Documentation was lacking regarding whether dressing changes were completed, and wound dressings were not dated or initialed as required by professional standards. Staff interviews revealed inconsistent communication about supply shortages and a lack of clear processes for ensuring that dressing supplies were available and accessible to all staff, particularly on weekends. Additionally, staff demonstrated a lack of knowledge regarding the identification and monitoring of sepsis, with some nurses unaware of the specific criteria for early recognition. There was also a failure to document baseline assessments after residents returned from wound clinic visits, and staff did not consistently monitor or document changes in residents' conditions, including signs of infection or sepsis. These deficiencies were observed through interviews, record reviews, and direct observation, and affected the care and treatment of all three residents reviewed.
Facility Lacks Comprehensive QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan, which is essential for maintaining and improving care and services. During the entrance conference, the administrator and director of nursing (DON) were unable to provide a written QAPI plan. Although the administrator had a template from TMF Quality Innovation Network, it had not been utilized to create a comprehensive QAPI plan. The administrator and DON acknowledged their responsibility for the QAPI program and mentioned ongoing performance improvement projects related to falls and pressure wound management. However, the absence of a formalized QAPI plan indicates a lack of structured guidance for these efforts. The facility's QAPI Program policy, updated in October 2024, was found to be inadequate. It did not outline how feedback from residents, representatives, and staff would be used to identify issues or opportunities for improvement. Additionally, the policy lacked details on maintaining effective systems for data collection and monitoring across departments. It also failed to describe methods for identifying, tracking, and analyzing adverse events or problem-prone concerns. Furthermore, the policy did not specify how performance indicators would be developed, monitored, or evaluated, nor did it include systematic approaches for determining underlying causes of problems. The facility assessment did not demonstrate integration with the QAPI program, highlighting a significant gap in the facility's quality assurance processes.
Failure to Conduct N95 Fit Testing for Staff
Penalty
Summary
The facility failed to ensure compliance with CDC guidance for fit testing of N95 respirators prior to use and annually. Observations and interviews revealed that staff, including a housekeeping assistant and nursing assistants, were using N95 masks without having undergone fit testing. The housekeeping assistant was observed placing an N95 mask over a regular surgical mask and was unaware of any fit testing. Similarly, a nursing assistant could not recall if she had completed fit testing. Interviews with other staff, including LPNs and the infection preventionist, confirmed that fit testing was not routinely conducted at the time of hire or annually, and was only performed on request. The facility's infection preventionist acknowledged the importance of fit testing for ensuring a tight seal and staff safety but admitted that it was not part of the regular protocol. The director of nursing expected staff entering COVID isolation rooms to have been fit tested but was unsure about the use of PAPRs, which were available but not observed in use. An untitled facility document allowed staff to decline fit testing without identifying the associated risks. The facility's policy referenced OSHA and CDC guidelines, which require a comprehensive respiratory protection program, including fit testing, but these were not being followed.
Failure to Assess Resident's Use of Power Lift Recliner
Penalty
Summary
The facility failed to assess a resident's ability to safely operate a power lift reclining chair and did not develop or implement policies and procedures related to the use of such chairs. The resident, who had no cognitive impairment but required substantial assistance for various activities, was found on the floor after sliding out of the recliner while trying to reposition herself. The incident occurred despite the resident having a history of falls and being at moderate risk for falls, as indicated in her care plan and fall risk assessment. Interviews with facility staff revealed that the responsibility for assessing the use of electric lift chairs lay with the nursing staff, specifically registered nurses or the Director of Nursing. However, no assessment was completed for the resident before she used the chair, and the facility lacked a policy on lift chairs. The resident confirmed she was not educated on the use of the recliner, and the facility's admission packet indicated that residents using lift chairs should be assessed by nursing or therapy.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible for residents or visitors to view. During an observation, a black three-ring binder labeled 'Survey Results' was found near the front entrance of the facility, containing survey results dated 9/14/2022. However, the results of the most recent federal recertification survey were not included, and there was no posted information indicating the availability of other results. The social services director confirmed that the most current survey results were not in the binder and were not posted elsewhere in the facility. The administrator was unaware of this issue, and no policy regarding the posting of survey results was provided.
Failure to Monitor and Notify Physician of Fluid Overload in Resident with Heart Failure
Penalty
Summary
The facility failed to comprehensively assess and monitor a resident with congestive heart failure for signs and symptoms of fluid overload and did not evaluate the effectiveness of physician-prescribed treatments. The resident, who was cognitively intact and had diagnoses including chronic right heart failure and atrial fibrillation, had a care plan that lacked individualized interventions or goals for managing fluid overload. Despite physician orders for daily weight monitoring, the facility did not consistently obtain or document the resident's weights, and there was no evidence that the physician was notified of the resident's refusals to be weighed. Between early December and late December, the resident's weight was not consistently documented, and significant weight gain was noted without timely physician notification. The resident's weight increased by 17 pounds over two weeks, and slight edema was observed, but the extent was not documented. The facility's staff, including nursing assistants and licensed practical nurses, acknowledged the resident's frequent refusals to be weighed but did not notify the physician of these refusals or monitor for fluid overload symptoms as required. Interviews with facility staff, including the nurse manager and DON, revealed that there was no protocol for notifying the physician when prescribed weights were refused. The DON expected that refusals and changes in condition would be documented and communicated to the physician, but this did not occur. The physician was unaware of the weight refusals and expected the nursing staff to assess and monitor for fluid overload symptoms, which was not adequately done. The facility did not provide a policy regarding the monitoring and notification process for such cases.
Systemic Failure in Pressure Ulcer Management Leads to Resident's Death
Penalty
Summary
The facility failed to implement a comprehensive system for pressure ulcer prevention and management, which led to significant deficiencies in the care of four residents with ongoing, recurrent, and deteriorating pressure wounds. The facility did not conduct comprehensive assessments, failed to monitor the wounds effectively, and did not involve physicians in a timely manner. This systemic failure resulted in one resident developing a stage 4 pressure ulcer that led to sepsis, osteomyelitis, and ultimately death. The resident in question had a history of pressure injuries and was at risk for developing new ones. Despite this, the facility did not update the resident's care plan to include necessary interventions such as turning and repositioning. The facility also failed to notify the physician of changes in the resident's condition, including increased drainage and pain, which delayed necessary medical intervention. The resident's wound assessments were inconsistent and did not accurately reflect the condition of the wounds, leading to inadequate treatment and monitoring. Additionally, the facility's wound care practices were inadequate, with treatments being applied without physician orders and assessments lacking critical information such as wound measurements and progress toward healing. The facility's staff, including the wound nurse, lacked formal training in wound management, contributing to the deficiencies in care. The lack of a structured turning and repositioning program further exacerbated the risk of pressure injuries for residents, highlighting a systemic issue in the facility's approach to wound care management.
Deficient QAPI/QAA Program Fails to Address Skin Integrity Issues
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement/Quality Assurance Activity (QAPI/QAA) program, which was necessary for identifying, assessing, and implementing appropriate plans of action related to impaired skin integrity and pressure injuries. The deficiency was identified through a review of QAPI/QAA project documents and plans from January to October 2024. The review revealed that QA meetings were held only in January, June, and October, and the documentation was inadequate. In January, there were no meeting agendas or minutes, and no corrective actions or comprehensive evaluations of previous project performance activities were documented. In June, the QA files lacked a comprehensive action plan, and although data on falls and infection control were provided, no comprehensive action plans were evaluated or revised. Additionally, ongoing issues with impaired skin integrity were identified in resident records, but no new quality improvement projects were developed to address these issues. In October, the QA file included a QAPI Meeting Agenda with attendee names but no areas of focus were identified. The Consultant Dietician Report indicated skin issues in three residents, but no nursing department data was provided, and no action plans were developed or implemented despite ongoing impaired skin integrity issues, one of which resulted in a resident's death. Interviews with facility staff revealed a lack of awareness and training regarding wound care and pressure ulcer management. The facility's QAPI program was supposed to be ongoing, facility-wide, and data-driven, focusing on care outcomes and quality of life, but it failed to track and measure performance, establish goals, identify deficiencies, analyze causes, develop corrective actions, and monitor effectiveness as required.
Failure to Notify Physician and Family of Pressure Injuries
Penalty
Summary
The facility failed to notify the physician and family or resident representative of new or existing wounds for four residents reviewed for pressure injuries. Resident 1, who was cognitively intact and dependent on staff for various activities, developed wounds on the buttocks that were not reported to the physician. Despite the presence of moisture-associated skin damage and signs of infection, the physician was not notified until the resident was sent to the emergency room with severe sepsis and sacral osteomyelitis. The family was also unaware of the pressure injury until informed by the emergency department. Resident 2 was at risk for pressure ulcers and developed a pressure sore on the left second toe, which was not reported to the physician for several months. The wound was initially identified as a pressure sore from shoes, and treatment was administered without physician notification. It was only after a significant delay that new orders were obtained from the physician for wound care, indicating a lack of timely communication regarding the resident's condition. Resident 3, who was cognitively intact and dependent for transfers and bed mobility, had multiple pressure ulcers identified over several months. Despite ongoing wound assessments and treatments, there was no evidence that the physician or family was notified of the new skin issues. Similarly, Resident 4 had a new coccyx wound and an ear wound from a hearing aid, but there was no indication that the physician was informed. Interviews with staff revealed a lack of clarity regarding the notification process and standing orders for wound care, contributing to the deficiency.
Inadequate Wound Care Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nursing staff were adequately trained and competent in pressure ulcer assessment and management, which could potentially affect all residents at risk for or with existing pressure ulcers. The facility's assessment included a section on staff competency in pressure ulcer prevention and treatment, but interviews revealed that the infection preventionist/wound nurse (IPWN-A), a licensed practical nurse (LPN), had not received training on wound care. Another LPN, LPN-D, also confirmed the lack of wound training at the facility. LPN-B mentioned receiving training from IPWN-A, but demonstrated a misunderstanding of pressure injury staging. The Director of Nursing (DON) and Administrator believed that IPWN-A had received wound training the previous year and expected her to monitor wound changes and consult with medical providers. However, a review of the facility's education transcripts showed that IPWN-A had only completed one training on wound identification and assessment from 2021 to 2024, with no further wound care training. The medical doctor (MD-B) expected the facility nurse to have expertise and provide additional training for staff dealing with wound issues. The Administrator stated that education was standard from annual reviews and monitoring by registered nurses, but competencies and education records were not provided upon request.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to potential cross-contamination and infection risks. Observations revealed that staff, including a Licensed Practical Nurse (LPN) and Nursing Assistants (NAs), did not adhere to EBP protocols when providing care to residents with conditions such as osteomyelitis, pressure ulcers, and indwelling urinary catheters. Staff entered rooms without performing hand hygiene or donning the required personal protective equipment (PPE), despite signage indicating the need for EBP. This included instances where staff assisted residents with transfers and personal care without using gowns and gloves. Additionally, the facility failed to ensure proper cleaning and disinfection of vital sign equipment between uses for two residents. Equipment used on a resident with a pressure ulcer was not disinfected before being used on another resident, contrary to the facility's policy requiring disinfection between each resident. Staff interviews revealed a lack of understanding and inconsistent practices regarding when EBP and equipment disinfection were necessary, with some staff believing EBP was only required for wound or catheter care. Hand hygiene practices were also inadequate, as observed with five residents. Staff, including dietary aides, did not perform hand hygiene before entering or after leaving residents' rooms, nor did they apply EBP when required. Interviews with staff, including the Infection Preventionist Wound Nurse (IPWN), highlighted a lack of training and documentation on EBP competencies, particularly for dietary staff. The facility's policies on hand hygiene, EBP, and equipment disinfection were not consistently followed, contributing to the deficiencies observed.
Failure to Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency as required by their policies and procedures. Two residents, identified as R2 and R5, were involved in separate incidents of alleged abuse by a nursing assistant. R2, who has a history of mild cognitive impairment and traumatic brain injury, reported being slapped on the foot by a nursing assistant, which was later confirmed by a family member. The facility was informed of this allegation by the local police chief but did not report it to the State Agency. R5, who has end-stage renal disease and anxiety disorders, reported being yelled at by the same nursing assistant due to incontinence issues. This allegation was documented by the social services director but was also not reported to the State Agency. Interviews with facility staff, including the social services director, director of nursing, and administrator, confirmed that the allegations were not reported as required. The facility's policy mandates immediate reporting of suspected abuse to the appropriate state agencies, but this was not followed. The social services director and other staff were unsure why the reports were not made, despite acknowledging the requirement to do so. The facility's failure to report these incidents represents a significant deficiency in adhering to established protocols for handling allegations of abuse and neglect.
Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of staff-to-resident abuse involving a resident with diagnoses including end-stage renal disease, PTSD, panic disorder, depression, and generalized anxiety disorder. The resident, who had intact cognition, reported that a night shift nursing assistant yelled at him due to incontinence, which upset him. The social services director documented the grievance but did not conduct a thorough investigation as required by the facility's policy. Interviews with the social services director, director of nursing, and administrator confirmed that no comprehensive investigation was conducted, despite the facility's policy mandating prompt and thorough investigations of abuse allegations. The policy also required interviewing relevant parties and suspending the accused employee pending investigation, which was not followed in this case. The nursing assistant's work hours were reduced, and they were reassigned to a different hallway, but these actions did not constitute a complete investigation.
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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 New Richland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeshore Rehabilitation Center Llc | 12.7 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Albert Lea | 14.9 mi | ★★★★★ | 5 | 0 |
| Parkview Care Center | 16.1 mi | ★★★★★ | 12 | 0 |
| St Johns On Fountain Lake | 16.2 mi | ★★★★★ | 15 | 0 |
| Thorne Crest Retirement Center | 17.7 mi | ★★★★★ | 26 | 0 |
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