Average — CMS composite of the measures below.
The next survey window likely opens around April 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 The Villas At Richfield during CMS and state inspections, most recent first.
A resident with severely impaired cognition, liver cancer, and severe malnutrition required 1-staff assist with eating, but was observed in a wheelchair with the lights off while the MDS coordinator stood next to him and fed him. Staff interviews showed uncertainty about whether they should sit or stand during feeding, while the DON stated residents should be assisted at eye level with the lights on unless the resident preferred otherwise.
Failure to Provide Requested Socks: A resident with intact cognition and diagnoses including HF and type II DM was observed barefoot in his wheelchair and while walking in the hallway and on the elevator after asking staff multiple times for socks. Staff acknowledged that residents should not be barefoot in common areas and stated gripper socks were available, but the resident was still left without socks.
Failure to Protect Resident Privacy During Toileting: A resident with hemiplegia/hemiparesis, aphasia, depression, and 1:1 monitoring was observed toileting with the bathroom door left open while a roommate’s visitor had direct line of sight. The NA left the door open to maintain supervision due to elopement concerns, but the resident said it bothered him to be seen on the toilet and he wanted privacy; the roommate’s privacy curtain was left open even though it could have blocked the view.
Failure to provide individual or group activities for a resident with severe cognitive impairment, dementia, and immobility. The resident’s MDS showed music was very important and that favorite activities, group activities, religious services, and going outside were important to her, while the care plan identified dependence on staff for activities and social interaction. Over several observations, she was found in bed with the lights on and no music, TV, or staff interaction beyond required care. NA staff said she did not get out of bed, did not attend group activities, and did not participate in individualized activities, while the RN stated TR and social services were responsible for activities and the TR described how residents were usually invited or provided in-room activities.
Failure to Assist a Resident With Eyeglasses Access: A resident with stroke, hemiplegia, myopia, and age-related cataracts requested eyeglasses multiple times and later reported worsening L eye vision and headaches when reading. Records and care notes did not show assistance with obtaining eyeglasses, and staff interviews confirmed they were unaware of resources or any specific policy for residents on EMA to obtain eyeglasses.
A resident at risk for falls had ordered interventions missing during observations: the call light was under the bed and out of reach, the bed was not in the lowest position, and the floor mat was folded up instead of placed next to the bed. The resident had moderate cognitive impairment, was dependent for mobility and personal care, and had diagnoses including lumbar spondylosis and syncope/collapse. Staff and the DON stated the resident’s fall interventions should have been in place as identified on the care plan.
A resident with impaired cognition, hemiplegia, malnutrition, and dependence on staff for eating was ordered 120 cc of Med Pass or Mighty Shake after meals, but unopened supplements were repeatedly found in her room. The resident stated staff did not open the shakes and she could not open them herself due to limited hand use; nursing staff observed the unopened supplements, one NA discarded warm shakes, and RN, RD, and DON statements confirmed staff should have assisted with supplement consumption and documentation.
A resident who was dependent for total body care, bed mobility, and transfers, and who was incontinent of bowel and bladder, received incontinence care from an NA and an LPN. After fecal care was provided, the NA did not change gloves or perform hand hygiene before applying cream, placing a new brief, repositioning the resident, and touching the pillow, blankets, and tray table with the same contaminated gloves. The NA acknowledged not changing gloves between dirty and clean cares, and the LPN and DON stated the expected practice was to remove soiled gloves, wash hands, and use clean gloves for subsequent care.
A resident with hemiplegia, hemiparesis, and alcohol use was allowed to go to an outside lab appointment without a formal community safety assessment to determine if he could go independently. Staff relied on BIMS, elopement risk, and their own judgment, despite OT noting impaired decision-making and safety awareness. When the resident did not return, staff delayed action based on LOA assumptions, later filed a missing person report, and the resident was found by EMS in a crosswalk and taken to the ED with injuries and fluctuating cognition.
A resident with cognitive impairment and risk factors for skin breakdown did not consistently receive care as outlined in the care plan, including the use of barrier cream, heel protectors, floating of heels, and geri-sleeves or long sleeves. Staff were observed not implementing these interventions, and some were unaware of the care plan requirements, resulting in a failure to provide care as ordered.
A resident with cognitive impairment and mental health diagnoses was not provided with preferred music-related activities, nor was she routinely notified or assisted to attend group activities. Staff were unaware of her person-centered goals for activity participation, and the facility's activity calendars lacked music-based options, resulting in unmet individual entertainment needs.
Two residents experienced deficiencies in wound and skin care, including a lack of assessment and documentation for significant bruising and an open area in one resident with multiple risk factors, and failure to implement or clarify a wound care order for another resident after hospitalization. Staff did not consistently document, monitor, or follow provider orders as required by facility policy, and the care provided did not match the prescribed treatments.
A resident with cognitive impairment and limited right hand movement experienced worsening contracture and loss of function, as the facility failed to appropriately assess and address range of motion needs. Despite concerns from the resident's family and staff acknowledgment of the importance of a hand brace, the physical therapy consult did not address the right hand's ROM, and no follow-up was conducted. The resident was observed unable to use silverware, relying on her left hand to eat.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident with PTSD, depression, and schizophrenia did not receive a comprehensive trauma-informed assessment or individualized care plan. Staff were unaware of the resident's trauma history and specific triggers, and the care plan lacked detailed interventions tailored to the resident's needs, contrary to facility policy.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, without proper justification documented.
Two residents experienced deficiencies in medical record documentation, including lack of assessment and documentation for significant bruising and an open wound, as well as improper administration and recording of diuretic medication despite clear physician orders. Staff interviews confirmed omissions and confusion in documentation practices, and the facility was unable to provide relevant policies when requested.
A resident with a suprapubic catheter was observed with their catheter bag on the floor while in a wheelchair, and staff failed to use the available cover to keep the bag off the floor. This occurred despite the resident's care plan and facility infection control policies requiring proper catheter care and placement to prevent infection.
The facility did not keep its survey results binder in a location that was easily accessible or visible to residents and visitors, as confirmed by interviews and observation. The binder was stored on a high shelf with other materials, and there was no policy in place regarding the posting of survey results.
A resident with moderate cognitive impairment had a bruised and swollen wrist, which was not reported to the State Agency within the required timeframe. Despite the facility's policy requiring such incidents to be reported, staff interviews revealed that the injury was not communicated to the SA, and the administrator was unaware of the situation. The incident highlights a failure in the facility's reporting procedures.
A resident with moderate cognitive impairment had a swollen, bruised, and tender wrist with no known cause, which was not investigated by the facility. Despite the facility's policy requiring investigation of such injuries, the social worker, DON, and administrator confirmed that no investigation took place. The facility's policy mandates reporting and investigating injuries of unknown origin, but this was not followed.
A resident with moderate cognitive impairment and a history of urinary retention was discharged from a facility to an assisted living facility without a necessary catheter. Despite multiple unsuccessful attempts by nurses to reinsert the catheter, the provider was not notified, and the discharge summary lacked critical information about the resident's condition. This failure to communicate and document essential information led to a deficiency in continuity of care.
A resident with moderate cognitive impairment and renal insufficiency was discharged from the hospital with a catheter for urinary retention, but the facility failed to include catheter care in the care plan. When the catheter came out, multiple nurses unsuccessfully attempted reinsertion without notifying the provider, contrary to protocol. The lack of specific catheter orders and failure to notify the provider led to inadequate care.
A facility failed to develop a care plan for a resident with Type 2 diabetes, who required daily insulin injections. Despite physician orders for both long-acting and short-acting insulin, the care plan lacked a focus on diabetic management. Nursing staff noted the resident's high blood glucose levels and acknowledged the absence of a care plan, which should have included interventions for monitoring glucose levels and dietary management. The facility's policy required a comprehensive care plan within 21 days of admission, which was not followed.
The facility failed to properly label, date, and discard food and beverages in the kitchen refrigerators, affecting 87 residents. During a kitchen tour, several items were found without proper dates, including veggie burgers, salad dressings, and thickened milk. The dietary manager confirmed these findings and mentioned a recent water leak as a possible cause for contamination. The registered dietician was unaware of the issue but expected staff to have resolved it. Facility policy requires opened containers to be dated and thickened liquids to be discarded after the use-by date.
A resident with moderate cognitive impairment and various diagnoses was left in a wheelchair with a mechanical lift sling visibly draped over his thighs, which bothered him. Staff interviews confirmed the sling was left in the wheelchair, contrary to the facility's expectations for promoting dignity. The facility's policy emphasized upholding residents' dignity and privacy, which was not followed in this case.
The facility failed to ensure safe medication administration for three residents who had medications left at their bedside without being assessed for self-administration. One resident had unauthorized creams, another self-applied a gel without an order, and a third had opioids left unattended. Staff were unaware of self-administration assessments, and the facility's process for obtaining orders was not followed.
A shared bathroom used by four residents was found with a brown substance on the wall and a sticky floor, which remained uncleaned over consecutive days. The housekeeper responsible had not cleaned the bathroom, relying on staff notifications for cleaning needs. The environmental director and DON expected daily cleaning and immediate response to soiling, as per facility policy, which was not followed.
A facility failed to conduct a timely care conference for a resident with malnutrition, anxiety, and depression, who was at risk for harm due to suicidal thoughts. Despite the requirement for quarterly care conferences, the facility did not document a conference after the resident's quarterly MDS was completed. Interviews revealed that the resident had not attended a care conference for some time, and the facility was behind schedule. The facility also lacked a policy related to care plans or care conferences.
The facility failed to provide adequate assistance with personal hygiene for two residents and dressing for one resident. A resident with intact cognition and medical conditions was observed with long facial hair despite preferring staff assistance. Another resident with memory issues was observed with long facial hair over several days, expressing discomfort. A third resident with severe cognitive impairment was repeatedly seen in a hospital gown with exposed skin, despite having clothing available. The facility's policy to maintain grooming and personal hygiene was not followed.
A facility failed to implement proper PPE practices for a resident under enhanced barrier precautions (EBP). The resident, with severe cognitive impairment and a feeding tube, required EBP during high-contact care activities. An LPN was observed administering medications and performing hygiene care using only gloves, without a gown, contrary to EBP requirements. The DON confirmed the need for EBP, and the facility's policy required gown and glove use, which was not followed, resulting in a deficiency.
A resident with cognitive impairment and mobility dependence was unable to access their call light due to improper placement, as observed during multiple checks. Staff interviews confirmed the oversight, and the facility lacked a call light policy.
Two residents in an LTC facility reported feeling embarrassed due to inadequate personal hygiene care. One resident, dependent on staff for hygiene due to paraplegia, expressed dissatisfaction with infrequent showers and reliance on her boyfriend for assistance. Another resident, with PTSD and depression, felt uncomfortable as her hair was not washed during scheduled care. Staff interviews revealed inconsistencies in care provision and a lack of a dignity policy, contributing to the deficiency.
A resident with quadriplegia and recent hospitalization for shortness of breath was left unattended during a nebulizer treatment in an LTC facility. The LPN administering the treatment left the room and did not return to remove the mask, leaving the resident with the mask on for over two hours. Facility policy required the nurse to stay with the resident during treatment, which was not followed, leading to a deficiency in respiratory care.
Failure to Provide a Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for 1 resident who had a significant change MDS indicating severely impaired cognition, liver cell carcinoma, and severe protein-calorie malnutrition, and who required substantial assistance with eating. The resident’s care plan identified a self-care deficit related to liver cell carcinoma with an intervention for assistance of 1 staff member with eating. During observation, the resident was sitting in a wheelchair in his room with the lights off, his bedside table positioned in front of him, and the MDS coordinator standing next to his wheelchair while assisting him to eat. Interviews showed staff were unsure whether they should sit or stand while assisting a resident with eating, although one NA stated they should sit down and converse with the resident and that the lights should be on. Another NA stated staff should sit next to the resident and have a conversation while assisting with meals, and that the lights should be on because it provides a more dignified experience. The DON stated staff should assist residents at eye level and the lights should be on unless the resident preferred to eat in the dark, and explained the MDS coordinator was standing because the resident’s chair was elevated.
Failure to Provide Requested Socks
Penalty
Summary
The facility failed to provide appropriate socks to a resident who requested them. The resident’s quarterly MDS indicated intact cognition and diagnoses of heart failure and type II diabetes. During observation, the resident was found barefoot in his wheelchair in his room and stated he had asked staff several times for socks and had not received any. Staff later observed the resident barefoot again while sitting in his wheelchair, and he was also barefoot when walking in the hallway and going to the elevator with PT. Multiple staff members acknowledged that the resident should not have been barefoot in the hallway or on the elevator and stated that socks, including gripper socks, were available in the facility. An NA told the resident he would have to wait for socks from laundry, and an LPN noted that the resident still had not been found socks. Staff interviews confirmed that residents should be wearing socks, especially when ambulating in common areas, and the DON stated this was important because the resident was diabetic and more susceptible to wounds and skin alterations. The facility did not have a policy addressing the concern.
Failure to Protect Resident Privacy During Toileting
Penalty
Summary
The facility failed to ensure personal privacy during toileting for one resident who was reviewed for privacy. The resident had an admission MDS indicating cognition was not assessed, required supervision or touching assistance for most ADLs including toilet hygiene and transfer, and was always continent of bowel and bladder. The resident’s diagnoses included hemiplegia and hemiparesis, aphasia, and depression. The care plan identified the resident as at risk for elopement due to cognitive impairment and a previous attempt to leave the facility, and provider orders indicated the resident was on 1:1 monitoring. During observation, the resident was assisted into the bathroom and transferred to the toilet by an NA while the bathroom door was left open. The resident’s roommate had a visitor present, and the visitor had direct line of sight to the resident on the toilet. Although the roommate had a privacy curtain that could have been pulled to block the view, it was left open. The resident stated he did not understand why he was receiving 1:1 supervision and said it bothered him that a visitor could observe him while he was on the toilet and that he would prefer privacy. The NA stated she left the bathroom door open to continue 1:1 supervision because she did not want the resident to escape through the adjoining room, and said she should have pulled the privacy curtain. An LPN and the DON stated the resident should have been given privacy by shutting the door or using a privacy curtain.
Failure to Provide Individual or Group Activities
Penalty
Summary
The facility failed to offer or provide individual or group activities for one resident with severely impaired cognition, vascular dementia, adult failure to thrive, and muscle weakness. The resident’s MDS indicated she required substantial assistance with bed mobility and was dependent on staff for transfers. Her annual MDS also identified listening to music as very important, and participating in favorite activities, group activities, religious services, and going outside as somewhat important. Her care plan stated she was dependent on staff for activities, cognitive stimulation, social interaction, and well-being related to cognitive deficits and immobility, with interventions including allowing rest periods, informing her early of scheduled programs, and thanking her for attending activity functions. During multiple observations over several days, the resident was repeatedly found lying in bed with the lights on and without music, television, or interactions from staff aside from required care such as medications, turning, repositioning, and wound care. Nursing assistants stated she did not get out of bed because she did not want to, did not attend group activities, and did not participate in individualized activities; one also stated the television or radio was not turned on because it was too loud and that she was only taken out of bed for group activities if the nurse told them to. The RN stated therapeutic recreation and social services were responsible for providing activities in the room or bringing residents to group activities, while the TR stated residents were made aware of group activities through the Daily Chronicle and individual invitations, and that residents who could not express preferences might be brought to activities for socialization. The DON stated resident activity preferences should be assessed, added to the care plan, and followed by nursing and activity staff.
Failure to Assist Resident With Eyeglasses Access
Penalty
Summary
The facility failed to utilize available resources to assist a resident in obtaining eyeglasses. R40’s records showed she had a history of stroke, high blood pressure, hemiplegia, myopia, and age-related cataracts. Her DO visit notes documented that eyeglasses were requested on 2/6/25 and again on 8/15/25, and her NP note on 4/8/26 recorded that she complained of worsening left eye vision and requested to see the eye doctor, resulting in an ophthalmology order on 4/15/26. R40 also stated during interview that her left eye was getting worse, she developed headaches when reading, and she needed eyeglasses. Despite these requests, the progress notes and care conference notes from 2/6/25 through 5/17/26 did not document that R40 was assisted with obtaining eyeglasses. Her communication care plan identified Spanish as her primary language and included a goal that residents’ needs would be anticipated and met, but there were no vision interventions. The HIM stated eyeglasses were not covered on R40’s EMA, the SS-D stated he was not aware of resources for someone on EMA to obtain eyeglasses and was not aware of R40’s request, and the administrator stated social services could look into eyeglasses resources for residents on EMA but had no specific resources or policies. The SS-D later stated there was no specific policy for resources on the acquisition of eyeglasses for residents on EMA.
Fall interventions not in place for a resident at risk for falls
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident at risk for falls. The resident’s quarterly MDS indicated moderate cognitive impairment, dependence on staff for personal hygiene, dressing, and mobility, and diagnoses of spondylosis of the lumbar region and syncope and collapse. The care plan identified the resident as at risk for falls due to low back pain and weakness and directed staff to keep the call light within reach, keep the bed low, and place a mat on the floor next to the bed while the resident was in bed. A fall review evaluation noted the resident had 1-2 falls in the last six months, was oriented to person but not always to place, and was unable to independently come to a standing position. During observation, the resident was found in bed with the bed against the wall and the call light under the bed with the cord stuck between the bed and the wall; the resident stated he did not know where the call light was and did not know what he would do if he needed assistance and could not reach it. A NA later confirmed the call light was under the bed and out of reach. On another observation, the resident’s bed was not in the lowest position and the floor mat was folded up and standing on edge next to the privacy curtain. Staff interviews indicated fall interventions should be in place at all times and should include the call light in reach, the bed low, and the mat on the floor next to the bed, and the DON stated interventions were expected to be in place as indicated on the care plan.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to ensure nutritional supplements were provided as ordered for a resident with moderately impaired cognition, dependence on staff for eating, encephalopathy, hemiplegia, and malnutrition. The resident’s nutritional assessment identified risk for malnutrition, and her weight decreased from 138.2 pounds on admission to 135 pounds on the most recent weight recorded. Her order directed staff to provide 120 cc of Med Pass or Mighty Shake after meals, and her care plan identified current nutritional status was less than 75% with swallowing issues and altered diet texture. During observations, the resident had multiple unopened Mighty Shakes left in her room, including warm shakes that had been dated several days earlier and another unopened shake on the bedside table the next day. The resident stated she did not know how often she was supposed to receive them and said staff did not open the shakes, but she would have drank them if they had been opened because she could not open them herself due to paralysis and limited use of her hands. Nursing staff observed the unopened supplements but did not provide them for consumption at the time, and one NA discarded the warm shakes. RN staff stated the shakes should have been opened for the resident, and the RD and DON stated staff were expected to assist residents as needed and accurately document supplement intake.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure staff followed proper infection control practices for hand hygiene during personal care for a resident who was cognitively intact, had impairment of one side of the upper body, bilateral lower extremity amputations, and was dependent on staff for total body care, bed mobility, and transfers. The resident also had a diagnosis of cerebral infarction, was incontinent of bowel and bladder, and required checks and changes with incontinence care as needed. Physician orders directed staff to follow enhanced barrier precautions while providing wound care and other high-contact care activities, and the care plan directed staff to follow enhanced barrier precautions when providing high-contact cares. During observation, a nursing assistant and an LPN donned gown and gloves and entered the resident’s room to provide incontinence care. After finding the resident had a bowel movement, the nursing assistant cleaned the peri area and then wiped feces from the resident’s bottom. Without changing gloves or completing hand hygiene, the nursing assistant applied cream to the bottom and peri area, opened and applied a new brief, and then assisted the resident back onto her back and closed the brief and pulled up pants. While repositioning the resident for offloading, the nursing assistant continued touching the pillow, blankets, and tray table with the same contaminated gloves. The nursing assistant stated they did not change gloves between dirty and clean cares and should have, and the LPN stated the expectation was to remove dirty gloves, wash hands, and put on a new clean pair of gloves. The DON/IP stated staff were expected to perform hand washing before donning gloves and after dirty or soiled cares, and that it was not acceptable to clean feces and then reposition the resident and touch pillows or other items.
Failure to Assess Community Safety and Track Resident After Outside Appointment
Penalty
Summary
The facility failed to complete a comprehensive community safety assessment to determine whether a resident with hemiplegia, hemiparesis, and alcohol use could safely attend outside appointments independently. The resident’s records showed he used a wheelchair, needed supervision for chair-to-bed transfers, was independent in wheelchair mobility, and had occupational therapy findings that his decision-making for routine activities was moderately impaired and his safety awareness was impaired. Although the resident was cognitively intact on BIMS testing and was not identified as at risk for elopement, the facility did not perform a formal assessment of his ability to go into the community alone before allowing him to leave for an outside laboratory appointment. On the day of the appointment, an LPN escorted the resident to the first floor to wait for transportation and gave him instructions to call the transportation company when he was finished. The resident had his cell phone with him and was able to make calls. When he had not returned by late afternoon, staff attempted to locate him by calling the outside laboratory, but the clinic was already closed. Staff also attempted to call the resident and his first contact without success. The nurse manager told staff to treat the resident as his own person and follow the facility’s leave of absence policy, including notifying police if he did not return after 24 hours. The resident did not return to the facility overnight, and staff later filed a missing person report with police and notified the physician. The resident was subsequently found by EMS in a crosswalk using his wheelchair with difficulty and was taken to the ED, where he had a wrapped left knee, an abrasion to the left elbow, and complaints of left elbow and left hip pain. The ED note stated he had difficulty providing details of the event, had intermittent altered mental status, and was admitted to the hospital with fluctuating cognitive levels, elevated white blood cell count, and a diagnosis of adult failure to thrive.
Failure to Follow Care Plan for Skin Integrity and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care in accordance with a resident's care plan for non-pressure related skin concerns. The resident had cognitive impairment, required substantial to maximal assistance with most ADLs, and was at risk for pressure ulcers and skin alterations due to incontinence and a history of skin issues. The care plan included interventions such as applying barrier cream after each incontinent episode, encouraging cleansing and drying of skin folds, using heel protectors while in bed, floating heels with pillows, turning and repositioning every two to three hours, and using geri-sleeves or long sleeves to prevent skin tears and bruises. Physician orders also specified the use of geri-sleeves or long sleeves during the day and removal at bedtime. Observations revealed that the resident was not consistently provided with the required interventions. The resident was seen in short sleeves without geri-sleeves on multiple occasions, and her heels were not floated or protected as directed in the care plan. Nursing assistants and a registered nurse confirmed that these interventions were not implemented, and staff were unaware of the need for certain care plan elements, such as heel protectors and arm coverings. Facility leadership confirmed the importance of these interventions and the expectation that staff follow the care plan, but the required care was not provided as documented.
Failure to Provide Resident with Preferred Music Activities
Penalty
Summary
The facility failed to ensure that a resident's preferred activities, specifically music-related entertainment, were available and accessible. The resident, who had cognitive impairment, anxiety, major depressive disorder, and obsessive-compulsive disorder, was dependent on staff for assistance with daily activities and required reminders and support to participate in activities due to her dementia. Despite documented preferences for music, particularly old rhythm and blues, and willingness to try new activities, the activity calendars for several months did not include any music-related activities. Observations showed that the activity director and other staff did not enter the resident's room to notify or assist her to attend group activities, and staff interviews confirmed that the resident was not routinely offered opportunities to participate in activities, nor were her specific preferences for music addressed. Interviews with staff revealed a lack of awareness regarding the resident's person-centered activity goals and interventions, particularly those related to music therapy, as outlined in her care plan. The activity director admitted to not offering music-based activities frequently and not inviting the resident to group activities during observed periods. Additionally, the facility was unable to provide an activity policy when requested. These actions and omissions resulted in the resident's individual entertainment needs and preferences not being met.
Failure to Assess, Monitor, and Document Bruises and Wounds; Failure to Implement Wound Orders
Penalty
Summary
The facility failed to ensure that bruises and non-pressure wounds were adequately assessed, monitored, and documented for two residents. One resident, who had multiple risk factors including cancer, diabetes, obesity, recent surgery, and was on anticoagulant therapy, was observed with significant bilateral bruising on her upper arms and an open area near her left armpit. Despite these findings, there was no documentation or treatment instruction for the open area, nor was there specific assessment or monitoring for the bruising. Multiple skin and wound assessments, daily skilled notes, and care plans lacked detailed information regarding the size, color, or progression of the bruises, and there was no evidence that the bruises were being monitored or that their resolution was tracked. Staff interviews confirmed that the bruises and open area had not been documented or measured as required by facility policy. Additionally, the same resident's care plan and physician orders required daily and weekly skin assessments, monitoring for signs of bleeding, and prompt treatment of skin breaks. However, documentation did not reflect that these interventions were consistently implemented. The facility's policy required notification of the provider, treatment orders, and care plan updates for significant skin alterations such as large or multiple bruises, but these steps were not followed. Staff interviews revealed a lack of clarity and consistency in how bruises and wounds were assessed, documented, and communicated among the care team. A second resident, with severe cognitive impairment and multiple comorbidities, had a physician order for wound care to the scrotum using a specific dimethicone-based cleanser following a recent hospitalization. However, this order was not reflected on the medication or treatment administration records, and staff were unaware of the specific product required, instead using alternative products without the ordered active ingredient. Interviews with nursing staff and review of records confirmed that the wound care order was not implemented or clarified, and the care provided did not match the provider's instructions. The facility's policy required staff to follow and clarify orders as needed, but this was not done in this case.
Failure to Assess and Maintain Range of Motion for Resident with Hand Contracture
Penalty
Summary
A resident with cognitive impairment and limited functional movement in the right hand experienced a decline in range of motion (ROM) and increased contracture, which was not appropriately assessed or addressed by the facility. The resident, who previously could hold silverware and brush her teeth, was observed to be unable to use silverware and instead used her left hand to pick up food. The resident's daughter expressed concern about the worsening contracture, and staff interviews revealed uncertainty about whether a hand brace was in use, despite its importance in maintaining function and preventing further loss of ROM. A physical therapy (PT) consult was ordered several months prior, but the consult only addressed wheelchair positioning and upper body strengthening, not the ROM needs of the right hand. The PT department had not reassessed the resident since that time, and the assistant director of nursing and physician assistant both acknowledged the significance of a brace for the resident's condition. Facility policy indicated that while therapy services are contracted, the facility retains responsibility for resident care and supervision.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Provide Individualized Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement individualized trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had a history of depression, schizophrenia, and PTSD related to religious persecution, starvation, and violence in Sudan, was not provided with a care plan that identified specific trauma triggers or individualized interventions. The Care Area Assessment Summary for psychosocial well-being was not completed, and the care plan only generically referenced the PTSD diagnosis without detailing the nature of the trauma or strategies to avoid re-traumatization. Interviews with facility staff, including a nursing assistant and a registered nurse, revealed a lack of awareness regarding the resident's PTSD diagnosis, history, and appropriate trauma-informed interventions. The assistant director of nursing confirmed that while the care plan included general interventions such as referrals to psychiatric services and encouragement of trauma-informed care, it did not specify resident-specific details or triggers. Facility policy required that care plans for residents with a history of trauma include goals and interventions to address potential triggers, which was not followed in this case.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Maintain Complete and Accurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the medical records for two residents. For one resident with diagnoses including cancer, wound infection, diabetes, and arthritis, there was a lack of documentation and assessment regarding significant bruising and an open area on the upper arms. Despite physician orders requiring daily skilled notes and monitoring for bruising, the medical record did not include specific assessments, measurements, or descriptions of the bruises or the open area. Progress notes, daily skilled notes, and skin and wound evaluation forms repeatedly omitted mention of these issues, and there were no treatment instructions for the open area. Interviews with nursing staff and the DON confirmed that the bruising and open area were not documented as required, and that the facility lacked a policy on complete and accurate documentation. For another resident receiving diuretic therapy for heart failure, the facility failed to accurately document medication administration in accordance with physician orders that required holding the medication if the resident's weight fell below a certain threshold. The medication administration records (MAR) showed that the resident received the diuretic multiple times when their weight was below the specified limit. Interviews with nursing staff and the nurse practitioner confirmed that the medication should have been held and not administered, as the resident's weight had consistently been below the threshold since admission. There was also confusion among staff regarding documentation codes on the MAR, with one LPN incorrectly interpreting staff initials as an indication that medication was not given, when in fact it was. Additionally, the facility did not provide a policy for medication administration when requested, and the DON confirmed that there was no record of non-narcotic medication wastage, despite staff claims that medication was wasted when not administered. The lack of accurate documentation and failure to follow physician orders for medication administration and skin assessments led to incomplete and inaccurate medical records for both residents.
Failure to Maintain Proper Catheter Bag Placement for Infection Control
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter was observed with their catheter bag placed on the floor while sitting in a wheelchair. The bag remained on the floor for an extended period and was later hooked onto the wheelchair strap but continued to touch the floor. The nursing assistant confirmed the improper placement and stated that a cover for the catheter bag was available but had not been used at the time, as it was left in the resident's room. The resident had significant medical conditions, including severe cognitive impairment, neurogenic bladder, diabetes, dementia, and was at risk for pressure ulcers. The care plan and physician orders required staff to provide catheter care per policy and ensure infection prevention measures were followed. The facility's Infection Prevention and Control Program directed staff to prevent infection by adhering to proper techniques, but staff failed to ensure the catheter bag was kept off the floor as required.
Survey Results Binder Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that its survey results were kept in a location that was readily accessible to all residents and visitors who wished to review them. During interviews, members of the resident council and a resident reported that the survey binder, which should be in the front lobby, was not visible or easily accessible, and one resident noted not having seen it for some time. Observation confirmed that the survey binder was not readily visible or available in the lobby without having to ask for it. The administrator acknowledged that the binder was stored in a basket with other binders on a higher shelf in the lobby, making it not easily accessible. Additionally, the facility did not have a policy regarding the posting of survey results.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with moderate cognitive impairment, identified as R2, to the State Agency (SA) within the required two-hour timeframe. On 2/19/25, R2 was noted to have a bruised and swollen left wrist with tenderness, but no falls or injuries were reported. The physician's assistant (PA)-A ordered an X-Ray for the wrist, but the progress notes did not document the staff's discovery of the injury. Interviews with various staff members, including a social worker, the director of nursing, registered nurses, and the PA, revealed that the injury was not reported to the SA as required by the facility's policy. The director of nursing and the administrator confirmed that the injury should have been reported to the SA, but it was not. RN-C, who discovered the swollen wrist, informed the PA but did not report it to the SA. The administrator was unaware of the injury until the survey, indicating a breakdown in communication and reporting procedures. The facility's Abuse Prohibition/Vulnerable Adult policy mandates that injuries of unknown origin be reported to the SA, but this protocol was not followed in this instance.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident, identified as R2, who had a swollen, bruised, and tender right wrist with no known related injuries or accidents. R2's Medicare 5-Day Minimum Data Set indicated moderate cognitive impairment. A physician's assistant noted the injury during a discussion about discharge planning, and an X-ray was ordered. However, the social worker, director of nursing, and administrator all confirmed that the injury had not been investigated, despite the facility's policy requiring such incidents to be reported and investigated. The facility's Abuse Prohibition/Vulnerable Adult policy stated that injuries of unknown origin should be reported to the State Agency and investigated, but this was not done in R2's case.
Failure to Ensure Continuity of Care During Resident Discharge
Penalty
Summary
The facility failed to ensure adequate and required information was communicated and documented for a resident's discharge, leading to a deficiency in continuity of care. The resident, who had moderate cognitive impairment, an indwelling catheter, a history of stroke, and renal insufficiency, was discharged to an assisted living facility without a catheter, despite requiring one for urinary retention. The discharge summary lacked an order for the catheter and did not mention the resident's urinary incontinence, bowel incontinence, and mental status. Multiple nurses attempted to reinsert the catheter without success, and the provider was not notified of the issue. The resident's family and staff at the assisted living facility confirmed that the resident arrived without a catheter, which was part of her treatment plan. The facility's discharge planning policy required the identification of resident needs and the development of plans to address them, which was not adhered to in this case.
Failure to Provide Comprehensive Catheter Care and Notify Provider
Penalty
Summary
The facility failed to comprehensively assess and develop a plan of care for a resident with an indwelling catheter. The resident, who had moderate cognitive impairment, a history of stroke, and renal insufficiency, was discharged from the hospital with a catheter due to urinary retention. However, the resident's care plan did not reflect the presence of the catheter, and there were no specific orders regarding the type, size, or maintenance of the catheter. This lack of documentation and planning led to confusion among the nursing staff about the appropriate catheter care. When the resident's catheter came out, multiple nurses attempted to reinsert it without success, and the provider was not notified for further direction. Despite the resident's need for the catheter due to urinary retention, the staff did not follow the expected protocol of notifying the provider or sending the resident to the emergency room. Interviews with the nursing staff and the director of nursing confirmed the absence of a catheter order and the failure to notify the provider when reinsertion attempts were unsuccessful. The facility's discharge planning policy also failed to address the resident's catheter needs adequately.
Failure to Develop Diabetic Management Care Plan
Penalty
Summary
The facility failed to develop a care plan to address diabetic management for a resident diagnosed with Type 2 diabetes, who required insulin injections daily. The resident's quarterly Minimum Data Set indicated cognitive intactness and a need for insulin management, yet the care plan printed on a later date lacked a focus area for diabetic management and corresponding interventions. Physician orders prescribed both long-acting and short-acting insulin, but the care plan did not reflect these orders or include necessary interventions for managing the resident's diabetes. Interviews with nursing staff revealed that the resident's blood glucose levels were higher than recommended, partly due to the resident's preference for double portions of food. Both registered nurses acknowledged the absence of a care plan for diabetic management, which should have included interventions for monitoring blood glucose levels and notifying the provider of high levels. The Director of Nursing confirmed that a comprehensive assessment and corresponding care plan should have been developed upon admission, including interventions related to diabetic management, medication administration, and nutritional services. The facility's care planning policy required a comprehensive individualized care plan to be developed no later than the twenty-first day after admission, but this was not adhered to in the resident's case.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure that food and beverages stored in the kitchen refrigerators were properly labeled, dated, and discarded according to professional standards. During a final tour of the kitchen area, several items were found in the kitchen freezer and refrigerator without proper notation of the date they were opened. These items included six veggie burgers in an opened plastic bag, a large plastic container of Asian salad dressing with a black crusty substance around the lid, and a plastic carton of thickened milk with a manufacturer's best by date that had passed. Additionally, large containers of various salad dressings and molasses were found with black crusty particles inside and outside the containers, some without any notation of the date they had been opened. The dietary manager (DM) confirmed these findings and acknowledged that the items should have been discarded. The DM was unsure when the refrigerator was last checked for dated or expired items and mentioned a recent water leak in the kitchen refrigerator as a possible cause for the black substance found on the containers. The registered dietician (RD) was unaware of the undated or undiscarded items but was aware of the water leak and expected staff to have reviewed the refrigerator to ensure the issue was resolved. The facility's policy on food storage indicated that all opened containers should be dated to ensure correct rotation and that thickened liquids should be discarded after the manufacturer's use-by date.
Failure to Promote Resident Dignity with Mechanical Lift Sling
Penalty
Summary
The facility failed to promote dignity for a resident, identified as R13, who was dependent on staff for activities of daily living and required the use of a mechanical lift for transfers. R13 had moderate cognitive impairment and various diagnoses, including moderate intellectual disabilities and Parkinsonism. Observations revealed that R13 was left in a wheelchair with a mechanical lift sling visibly draped over his thighs and hanging out the back of the wheelchair. This was noted to bother R13, as confirmed by both R13 and a resident representative. Interviews with staff, including a nursing assistant and the interim care coordinator LPN, confirmed that the mechanical lift sling was left in the wheelchair, which was against the facility's expectations for promoting dignity. The director of nursing also stated that mechanical lift slings should be removed or hidden to maintain residents' privacy and dignity. The facility's policy on resident rights emphasized upholding the dignity and privacy of all residents, which was not adhered to in this instance.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure safe medication administration for three residents who had medications left at their bedside without being assessed as safe to self-administer. Resident R79, who was cognitively intact and receiving hospice services, was observed with antibiotic and pain relief creams at her bedside, which were not ordered or assessed for self-administration. The nursing staff, including a nursing assistant and an LPN, were unaware of any self-administration assessment for R79, and the medications were removed after being discovered. Resident R74, also cognitively intact, was found to have Diclofenac Sodium External Gel in his dresser, which he reported applying independently without a self-administration order or assessment. The EMAR indicated that staff were signing off on the application of the gel, despite the resident self-administering it. Interviews with nursing staff revealed a lack of awareness of any self-administration orders for R74, and the facility's process for obtaining such orders was not followed. Resident R354, who had a history of substance use disorder, was observed with a cup of medications, including oxycodone, on his bedside table. The medications had been left there by an LPN without a self-administration order or assessment. The DON confirmed that the facility's process required a SAM assessment and physician order before allowing residents to self-administer medications. The facility's policy stated that residents could self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team.
Failure to Maintain Cleanliness in Shared Resident Bathroom
Penalty
Summary
The facility failed to maintain a clean and safe environment for four residents sharing a bathroom. Observations on consecutive days revealed a brown substance smeared on the doorframe and wall, and a sticky floor in the shared bathroom. Despite these conditions, the bathroom was not cleaned promptly, as confirmed by the housekeeper responsible for the area. The housekeeper admitted to not cleaning the bathroom on the previous day and stated that the usual practice was to clean based on staff notifications or routine checks. Interviews with the environmental director and the director of nursing highlighted an expectation for daily cleaning and immediate attention to soiled areas. The environmental director conducted daily inspections and expected housekeeping staff to clean resident bathrooms every day and respond quickly to soiling. The director of nursing emphasized the importance of maintaining hygiene and infection control, expecting nursing staff to either clean or notify housekeeping immediately when bathrooms were soiled. The facility's policy on daily cleaning procedures included instructions for spot cleaning visibly soiled walls and mopping floors, which were not adhered to in this instance.
Failure to Conduct Timely Care Conference for Resident
Penalty
Summary
The facility failed to provide a care conference for a resident, identified as R68, to review and revise their care plan with the interdisciplinary team. R68 was cognitively intact and had diagnoses including malnutrition, anxiety, and depression. The resident's care plan, revised on 7/26/24, noted that R68 was a vulnerable adult at risk for harm related to suicidal thoughts and was working with relocation services for housing. Despite the requirement for quarterly care conferences, the facility did not document a care conference after R68's quarterly Minimum Data Set (MDS) was completed. Interviews revealed that R68 had not been offered or attended a care conference for some time and could not recall the last one. The director of social services confirmed that the last care conference for R68 was held on 4/1/24, and acknowledged that the facility was behind schedule for care conferences. The interim administrator confirmed that care conferences should follow the resident's MDS calendar and should have been rescheduled after a hospital visit caused a cancellation. The facility lacked a policy related to care plans or care conferences, as confirmed by the Director of Nursing (DON).
Deficiencies in Personal Hygiene and Dressing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for two residents and dressing for one resident, as observed during a survey. Resident R30, who had intact cognition and required assistance with personal hygiene due to conditions such as hypertension, renal insufficiency, and diabetes, was observed with long facial hair on multiple occasions. Despite expressing a preference for staff assistance with shaving, R30 had not received help recently, as confirmed by nursing staff who were unsure of the last time R30 was shaved. Resident R12, who had memory problems and poor decision-making skills, was dependent on staff for personal hygiene and dressing. R12 was observed with long facial hair over several days and expressed discomfort with the situation. Staff interviews revealed that R12 could not shave himself and required assistance, yet no recent shaving assistance had been provided, despite R12's ability to communicate his needs. Resident R66, with severe cognitive impairment and non-verbal communication, required total assistance with ADLs. R66 was repeatedly observed in a hospital gown with exposed skin in the dining area, despite having clothing available. A family member expressed concern about R66's state of dress, and staff confirmed that R66 usually wore a hospital gown for comfort and ease of care. The facility's policy indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and personal hygiene, which was not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate donning and doffing of personal protective equipment (PPE) practices to prevent the spread of infection for a resident observed under enhanced barrier precautions (EBP). The resident, identified as having severe cognitive impairment and multiple diagnoses, including a feeding tube, required extensive assistance for activities of daily living. The care plan for the resident specified the need for EBP, including the use of gowns and gloves during high-contact care activities. However, during an observation, a licensed practical nurse (LPN) was seen administering medications and performing hygiene care for the resident using only gloves, without donning a gown, contrary to the EBP requirements. The LPN confirmed that she only wore gloves when administering medications via the feeding tube and was not aware of the requirement to wear a gown. The director of nursing (DON) confirmed that the resident was on EBP due to the feeding tube and that staff were expected to follow these precautions to prevent infections. The facility's policy, revised earlier in the year, indicated that EBP required targeted gown and glove use during high-contact care activities, and PPE should be available near or outside the resident's room. Despite this policy, the LPN did not adhere to the EBP guidelines, leading to a deficiency in infection control practices.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was cognitively impaired and dependent on staff for activities of daily living and mobility. The resident's care plan did not document the use or placement of the call light. During multiple observations, the resident was unable to reach the call light, which was placed on a pillow on the nightstand table behind him and covered with a blanket. The resident expressed that he could use the call light if it was placed on his legs, but it was not within his reach. Interviews with staff, including a nursing assistant and an LPN, confirmed that the call light was not accessible to the resident. The LPN acknowledged that the call light should have been placed within reach when the resident was put to bed. The Director of Nursing was unaware of the issue but stated that her expectation was for call lights to be within reach at all times. The facility did not have a policy on call lights, which contributed to the deficiency.
Inadequate Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care to two residents, leading to feelings of embarrassment and discomfort. One resident, who had intact cognition and required total assistance with personal hygiene due to paraplegia and other conditions, reported feeling unclean and embarrassed by her appearance. She expressed dissatisfaction with the frequency of her showers, which were scheduled only once a week, and noted that her boyfriend had been relied upon to assist with her hygiene needs. Observations confirmed that her hair appeared oily and uncombed, and she felt her hygiene needs were not being met adequately by the staff. Another resident, also with intact cognition and dependent on staff for personal hygiene, expressed similar concerns. She reported that her hair was not washed during her scheduled shower, leaving her feeling embarrassed and uncomfortable. This resident, who had a history of PTSD, anxiety, and depression, indicated that she found it difficult to ask for help, which compounded her feelings of embarrassment about her appearance. Observations confirmed that her hair appeared oily, and she expressed a desire for assistance in maintaining her personal hygiene. Interviews with staff revealed inconsistencies in the provision of care, with some staff members acknowledging the residents' needs but failing to address them adequately. The facility lacked a dignity policy, and the existing policy on activities of daily living emphasized the importance of person-centered care but was not effectively implemented. Staff interviews highlighted a lack of communication and understanding of the residents' preferences and needs, contributing to the deficiency in care.
Failure to Monitor Resident During Nebulizer Treatment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R2, who was left unattended during and after a nebulizer treatment. R2, who was cognitively intact but physically dependent on staff due to conditions such as quadriplegia and a traumatic spinal cord injury, required substantial assistance for daily activities. The resident had been recently hospitalized for shortness of breath and was readmitted to the facility with new orders for nebulizer treatments. On the night of the incident, R2 was left alone with the nebulizer mask on for over two hours, despite being unable to remove it independently due to his physical limitations. The incident occurred when LPN-C administered the nebulizer treatment and left the room, failing to return promptly to remove the mask. R2's roommate eventually alerted a nursing assistant (NA-A) about the situation, who then removed the mask and turned off the machine. Interviews with staff, including LPN-B, LPN-A, and RN-A, confirmed that the standard procedure required the administering nurse to stay with the resident during the treatment to monitor for side effects and changes in respiratory status. The facility's policy also mandated that the nurse remain with the resident unless they were assessed to self-administer the treatment, which R2 was not. The director of nursing (DON) and a pharmacy consultant confirmed that R2 had not been assessed to self-administer the nebulizer treatments, emphasizing the importance of monitoring due to the newness of the treatments for R2. The facility's medication administration procedures outlined the necessity of staying with the resident during nebulizer treatments to ensure safety and effectiveness, which was not adhered to in this case. This oversight in care led to a deficiency in the facility's respiratory care protocol for R2.
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 1,041 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — 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 Richfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Bloomington Llc | 1.9 mi | ★★★★★ | 12 | 0 |
| Martin Luther Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Mount Olivet Careview Home | 2.9 mi | ★★★★★ | 7 | 0 |
| Mount Olivet Home | 2.9 mi | ★★★★★ | 7 | 0 |
| Edenbrook Of Edina | 3.1 mi | ★★★★★ | 15 | 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.