Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tranquility Of Richmond Heights during CMS and state inspections, most recent first.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences.
A resident with multiple medical conditions was not documented as having their guardian's concerns addressed after the guardian was not notified about a scheduled orthopedic follow-up appointment. The guardian only learned of the appointment after the resident was absent, voiced concerns to the Administrator and DON, but these concerns were not recorded in the medical record or concern log, contrary to facility policy.
Surveyors found the dumpster area unsanitary, with the lid and enclosure left open and significant debris such as cups, plastic wrap, gloves, and food wrappers scattered around. The Dietary Manager confirmed the findings and indicated that the maintenance director was responsible for maintaining the area.
The facility did not implement enhanced barrier precautions for multiple residents with wounds or indwelling medical devices, as required by CDC guidance, resulting in a lack of signage, PPE availability, and staff adherence during high-contact care activities. Staff interviews and observations confirmed inconsistent use of gowns and gloves, and a general lack of awareness regarding EBP. Additionally, the facility had not developed or implemented a water management program or Legionella risk assessment, despite having relevant policies and resources.
The facility did not ensure that education on the risks and benefits of flu and pneumonia vaccines was provided or documented, and failed to obtain written consent for these immunizations. Several residents with complex medical conditions were affected, with consent forms either missing, incomplete, or only indicating verbal consent or declination without specifying who made the decision or providing a signature. Staff confirmed that forms were not properly completed, following instructions from the previous DON.
The facility did not provide documented education on COVID-19 vaccine risks and benefits or obtain written consent for immunization for five residents with complex medical conditions. Consent forms were incomplete, often only noting a verbal declination without specifying who made the decision, and lacked signatures. Staff interviews confirmed that written consent and proper documentation were not obtained, contrary to facility policy.
A resident with end stage renal disease who required dialysis did not have consistent communication or documentation maintained between the facility and the dialysis center. Staff interviews confirmed that the resident refused vital sign checks and did not return communication sheets from the dialysis center, and the facility did not retain copies or reach out directly to the dialysis provider, resulting in a lack of required monitoring and documentation.
Pharmacy recommendations for medication changes, lab monitoring, and therapy evaluations were not reviewed or addressed by a physician in a timely manner for several residents with complex medical and psychiatric conditions. Delays ranged from several weeks to months, affecting the management of anticoagulants, sedating medications, and duplicate therapies, with documentation confirming the lack of prompt physician response.
The facility did not ensure routine nutritional assessments and monitoring for two residents with complex medical needs, resulting in missed weight records, significant weight changes, and delayed care planning. Both residents experienced extended periods without nutritional oversight due to a lapse in dietitian services, as confirmed by staff interviews and record reviews.
The facility failed to notify two residents about past due payments, resulting in 30-day discharge notices without proper documentation. One resident, dependent on staff for daily activities, was unaware of insurance issues leading to nonpayment. Another resident, independent in daily activities, was not informed about the option to appeal the discharge. Staff interviews revealed a lack of awareness and documentation regarding the discharge notices, violating facility policy.
A resident with multiple health issues, including cancer and dementia, did not receive necessary assistance and care at an LTC facility. The resident was found incontinent and lethargic, with staff failing to provide incontinence care or recognize her deteriorating condition. The resident's family had to intervene, and she was eventually admitted to the hospital, where her condition was found to have worsened significantly.
A resident with multiple health conditions was admitted to the hospital, but the facility failed to document this event. The DON stated that the regional nurse advised against documenting hospital admissions, and the resident's medications were incorrectly marked as given while the resident was hospitalized. The facility was aware of the admission, but there was no written record of notification.
A resident with cognitive impairments was left unattended in a facility transport van without air conditioning for 20 to 30 minutes, leading to discomfort and a late arrival at a medical appointment. The incident occurred when an employee left the resident in the van to retrieve another resident, resulting in inadequate supervision and safety measures.
The facility failed to provide scheduled activities and support residents' mental and psychosocial wellbeing. Observations revealed that residents were left in the common area watching television or sleeping without any organized activities, and a scheduled scenic ride was canceled without an alternative activity provided. Interviews confirmed that there were not enough activities offered, contrary to the facility's policy.
The facility failed to ensure a dignified eating experience for three residents. Two STNAs were observed using their cell phones and not being seated while feeding the residents, violating the facility's policy on maintaining resident dignity during meals.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Document Guardian's Concerns Regarding Resident Care
Penalty
Summary
The facility failed to document concerns raised by a resident's guardian regarding the resident's care, specifically related to notification about a scheduled follow-up appointment with an orthopedic physician. The resident, who had diagnoses including fractured pelvis and left arm, anemia, anxiety, dementia, depression, neuromuscular dysfunction of the bladder, and schizophrenia, was admitted with a scheduled orthopedic follow-up. The guardian was not informed of the appointment and only learned of it when another family member visited and found the resident absent. The guardian expressed her concerns to the Administrator and the DON, but there was no documentation of these concerns in the resident's medical record or in the facility's Concern Log. Facility policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, there was no record of the guardian's expressed concerns or the facility's response. Interviews with facility leadership confirmed the lack of documentation regarding the guardian's complaints about notification of appointments or other care concerns during the resident's stay.
Unsanitary Dumpster Area and Improper Refuse Disposal
Penalty
Summary
Surveyors observed that the dumpster area was not maintained in a sanitary condition. The lid of the dumpster and the enclosure were both left open, and there was significant debris, including cups, plastic wrap, gloves, and food wrappers, scattered around the dumpster inside the enclosure. The Dietary Manager confirmed these findings during the observation and stated that the maintenance director was responsible for the upkeep of the dumpster area. This deficiency had the potential to affect all residents in the facility, which had a census of 48 at the time of the survey.
Failure to Implement Enhanced Barrier Precautions and Water Management Program
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required for residents with wounds or indwelling medical devices, affecting nine residents out of ten reviewed for transmission-based precautions and EBP. Medical record reviews revealed that several residents had conditions such as indwelling Foley catheters, suprapubic catheters, dialysis catheters, PICC lines, feeding tubes, and chronic wounds, all of which necessitate the use of gowns and gloves during high-contact care activities according to CDC guidance. Despite care plans and, in some cases, physician orders indicating the need for EBP, there was a lack of signage, PPE availability, and staff adherence to these precautions throughout the facility. Observations confirmed that only one resident room had signage and PPE indicating isolation precautions, while other rooms with residents requiring EBP had neither. During direct care activities such as wound care, tube feeding, and catheter care, staff members did not don gowns or have access to appropriate PPE, and there was no signage to alert staff to the need for EBP. Interviews with staff, including laundry personnel and CNAs, revealed a lack of awareness and inconsistent practices regarding EBP, with some staff recalling that PPE was previously provided but was no longer being used as required. Additionally, the facility failed to develop and implement a water management program and Legionella risk assessment, as confirmed by the Maintenance Director and Administrator. Despite having a policy and access to a CDC toolkit for Legionella control, no risk assessment or water management plan was in place. This omission had the potential to affect all residents in the facility, as there was no systematic approach to identifying or mitigating risks associated with Legionella in the water system.
Failure to Provide and Document Immunization Education and Consent
Penalty
Summary
The facility failed to ensure that education on the risks and benefits of influenza and pneumococcal immunizations was provided to residents or their representatives, and failed to obtain written consent for these vaccinations. In multiple cases, consent forms were either missing, incomplete, or only indicated verbal consent or declination without specifying who made the decision or providing a signature. For example, some forms did not indicate whether the resident or a representative provided consent or declination, and there was no documentation that education was given regarding the vaccines. Several residents with complex medical histories, including conditions such as hypertension, dementia, hemiplegia, Alzheimer's disease, Parkinson's disease, end stage renal disease, and dependence on renal dialysis, were affected by these documentation failures. In some instances, residents received vaccinations despite the medical record indicating a verbal declination, and in other cases, there was no consent form present at all for administered vaccines. The facility's own policies required that education be provided and documented, and that consent or declination be recorded in the medical record, but these steps were not consistently followed. Staff interviews confirmed that the immunization consent forms lacked signatures and did not specify who provided consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. This practice resulted in incomplete documentation and a lack of evidence that residents or their representatives were properly informed or had provided written consent for immunizations.
Failure to Provide COVID-19 Vaccine Education and Obtain Written Consent
Penalty
Summary
The facility failed to provide education on the risks and benefits of COVID-19 immunization and did not obtain written consent for COVID-19 vaccinations for five residents. Medical record reviews for these residents, who had complex medical histories including hypertension, dementia, cerebrovascular disease, dysphagia, chronic kidney disease, Alzheimer's disease, Parkinson's disease, and end stage renal disease, revealed that COVID-19 vaccination consent forms were either not dated, not signed, or only indicated a verbal declination without specifying whether the decision was made by the resident or a representative. There was also no documentation confirming that education on immunization risks and benefits had been provided. Interviews with facility staff confirmed that the consent forms lacked signatures and did not indicate who provided the consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. Review of the facility's policy indicated that resources and counseling on the importance of COVID-19 vaccination were to be offered, but this was not reflected in the documentation for the affected residents.
Failure to Maintain Communication and Monitoring for Dialysis Care
Penalty
Summary
The facility failed to ensure proper communication and monitoring between the facility and the dialysis center for a resident with end stage renal disease who was dependent on dialysis. The resident's care plan required regular communication with the dialysis center, monitoring of the vascular access site, and documentation of post-dialysis observations. However, review of the medical record showed that dialysis communication was only documented on two occasions, with no additional evidence of ongoing communication or documentation in the resident's record or the facility's dialysis communication book. Interviews with staff revealed that the resident consistently refused to have vital signs taken before and after dialysis and would not return the dialysis communication sheets from the dialysis center. The RN confirmed that no communication or documentation was provided upon the resident's return from dialysis, and the DON acknowledged that the facility did not retain copies of the communication sheets nor did they reach out directly to the dialysis center. Facility policy required documentation of dialysis-related care and communication, but this was not consistently followed for the resident in question.
Failure to Timely Address Pharmacy Recommendations by Physician
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and addressed by a physician in a timely manner for multiple residents. For one resident with multiple chronic conditions, pharmacy recommendations regarding necessary lab monitoring for anticoagulant therapy, discontinuation of a sedating muscle relaxant, and evaluation of duplicate antihypertensive therapy were not addressed by a physician for several weeks to months. Documentation showed that the recommended labs and medication changes were delayed, and the resident continued on the medications until well after the recommendations were made. Another resident with complex psychiatric and medical diagnoses was receiving multiple medications, including anticoagulants and anti-inflammatories. The pharmacist recommended discontinuing Naproxen due to bleeding risk, limiting the duration of an as-needed anxiolytic, and obtaining regular blood counts to monitor for bleeding. These recommendations were not addressed by the physician in a timely manner, with some responses delayed by over a month and others not documented at all, despite the physician being present in the facility weekly. A third resident with chronic venous insufficiency and psychiatric diagnoses had pharmacy recommendations for a gradual dose reduction of a sleep aid and re-evaluation of antihypertensive therapy. These recommendations were also not addressed by a physician until two months after they were made. Interviews with the DON confirmed the lack of timely physician response to pharmacy recommendations, and no additional evidence was found to show that the recommendations were addressed promptly.
Failure to Routinely Assess and Monitor Resident Nutrition
Penalty
Summary
The facility failed to ensure that residents were routinely assessed and monitored for nutritional status, resulting in lapses in care for two residents. One resident with multiple complex diagnoses, including hemiplegia, diabetes, heart failure, and chronic kidney disease, was admitted and placed on a regular diet with PEG tube feedings. Despite significant weight fluctuations and a 12% weight gain over five months, there were missing weight records for two months and no nutritional assessment or care plan was completed from admission until nearly seven months later. The registered dietitian supervisor confirmed the absence of prior assessments and identified the resident as high risk for nutritional issues. Another resident with end stage renal disease, diabetes, heart failure, and blindness experienced a 7.5% weight loss over one month and had not received a nutritional assessment or care plan from admission until over five months later. The nutrition note indicated significant weight loss, underweight BMI, and lack of communication with the dialysis dietitian. Both the registered dietitian supervisor and the administrator acknowledged a lapse in dietitian services for several months, and there was no evidence of nutritional oversight or monitoring for these residents during that period.
Failure to Notify Residents of Payment Issues and Discharge Rights
Penalty
Summary
The facility failed to provide timely notification to two residents regarding past due payments, resulting in the issuance of a 30-day discharge notice without proper documentation in the medical records. Resident #32, who had been residing in the facility for over a year, was not informed about the outstanding payments until receiving the discharge notice. The resident, who was cognitively intact and dependent on staff for daily activities, was unaware of the facility's failure to submit necessary documentation to the insurance company, which led to the nonpayment issue. The resident had filed an appeal against the discharge notice but had not been updated about the hearing. Similarly, Resident #7, who was cognitively intact and independent in daily activities, was also issued a 30-day discharge notice without prior notification of outstanding payments. The resident was not informed about the option to appeal the discharge notice and expressed confusion about the sudden change in her residency status. The facility's policy required documentation of discussions with residents regarding nonpayment, which was not adhered to in these cases. Interviews with facility staff revealed a lack of awareness about the insurance payment issues and a failure to document the discharge notices and reasons in the medical records. The Director of Nursing expressed skepticism about Resident #32's claims, while the Administrator acknowledged the oversight in documentation. The facility's policy on transfers and discharges was not followed, leading to non-compliance with regulatory requirements.
Failure to Provide Assistance and Recognize Change in Condition
Penalty
Summary
The facility failed to provide necessary assistance and recognize a change in condition for Resident #100, who was admitted with multiple health issues including breast cancer, dementia, and multiple sclerosis. The resident was moderately cognitively impaired and required supervision for daily activities. On a scheduled day for a medical appointment, the resident was found incontinent of a large amount of stool, which delayed her appointment. The resident's daughter had to reschedule the appointment and later found that her mother was not eating or drinking properly, a change that was not communicated by the facility. The resident's sister arrived to take her to a radiation treatment and found her in bed, incontinent, and not ready for the appointment. Despite requesting assistance from the staff, the sister was informed that the resident was self-sufficient in toileting and had to clean her up herself. The resident was lethargic and unable to stand, which was a significant change from her usual condition. The sister managed to reschedule the appointment, but upon arrival, the resident was sent to the ER due to her deteriorated state and was subsequently admitted to the hospital. The facility did not document the resident's whereabouts or condition from the time she left for her appointment until the next day when the LPN contacted the family. The Director of Nursing confirmed the lack of documentation and acknowledged the resident's drastic change in condition. The family was dissatisfied with the care provided, and the resident was eventually discharged from the hospital to her daughter's home, where she passed away.
Failure to Document Resident's Hospital Admission
Penalty
Summary
The facility failed to ensure appropriate and accurate medical record documentation for a resident who was admitted to the hospital. The resident, who had a history of breast cancer, dementia, multiple sclerosis, high blood pressure, a left mastectomy, and a psychotic disorder with delusions, was moderately cognitively impaired and required supervision for all care. On the day of the incident, the resident missed a scheduled appointment due to incontinence and was later taken to a rescheduled appointment. However, there was no documentation from the time the resident left the facility until the next morning when an LPN contacted the resident's daughter, who informed the facility that the resident had been admitted to the hospital and would not be returning. The Director of Nursing (DON) was unable to recall who notified the facility about the resident's hospital admission and stated that the regional nurse advised against documenting hospital admissions in the medical record. Despite this, the August Medication Administration Record indicated that the resident's morning medications were marked as given, even though the resident was in the hospital at that time. The DON confirmed the lack of documentation regarding the resident's whereabouts and acknowledged that the facility was aware of the hospital admission, although there was no written record of this notification.
Resident Left Unattended in Hot Transport Van
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of a resident with cognitive and neurological impairments, including dementia, who was at risk for falls and poor decision-making. The resident was left unattended in a facility transport van without air conditioning for an extended period. On the day of the incident, the resident was scheduled for a medical appointment and was loaded onto the transport van by an employee. The employee left the van door open and went to retrieve another resident, who was not ready for transport. This delay resulted in the resident being left in the van for 20 to 30 minutes without air conditioning, despite the outdoor temperature being 85 degrees Fahrenheit. The resident reported feeling unwell, experiencing a headache, and sweating due to the conditions in the van. The employee confirmed that the air conditioning was not left on during this time and that the resident arrived late to her medical appointment. This incident was part of a broader investigation into the facility's compliance with safety and supervision standards, specifically regarding transportation to outside appointments.
Failure to Provide Scheduled Activities and Support Residents' Wellbeing
Penalty
Summary
The facility failed to provide scheduled activities and support the residents' mental and psychosocial wellbeing. On the specified date, the activity calendar listed room visits, exercise, brain teasers, and a scenic ride with an ice cream stop. However, observations revealed that residents were left in the common area watching television or sleeping without any organized activities. The scenic ride was canceled due to a broken bus window, and no alternative activities were provided for the residents. Staff were observed seated at the nurse's desk, and no staff were present to engage the residents in activities during multiple observations throughout the day. Interviews with residents confirmed that there were not enough activities offered, and they spent a lot of time watching television. The facility's policy stated that activities should include religious programs, exercise programs, social activities, education programs, and indoor/outdoor activities, but these were not provided as scheduled. The deficiency affected three residents directly and had the potential to affect nine others observed for participation in activities.
Failure to Ensure Dignified Eating Experience for Residents
Penalty
Summary
The facility failed to ensure residents had a dignified eating experience, affecting three residents. Resident #12, who had epilepsy, legal blindness, and cerebral infarction, required moderate assistance for eating. Resident #19, diagnosed with multiple sclerosis, quadriplegia, and muscle weakness, had intact cognition and required setup and cleanup for eating. Resident #34, with unspecified dementia and legal blindness, required supervision and touch assistance with eating. During an observation, STNA #203 was seen using her cell phone while feeding Resident #19, and STNA #204 was observed standing and using her cell phone while feeding Residents #12 and #34. Both STNAs admitted they should not have been using their cell phones and should have been seated while feeding the residents. The facility's policy on Promoting/Maintaining Resident Dignity During Meals, dated 01/01/24, stated that staff should focus on the resident, address them individually, and be seated while feeding them. The actions of STNA #203 and STNA #204 were in direct violation of this policy, leading to a failure in providing a dignified eating experience for the residents. This deficiency was investigated under Complaint Number OH00152849.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richmond Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grande Pointe Healthcare Commu | 1.1 mi | ★★★★★ | 3 | 0 |
| Highland Pointe Health & Rehab Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Avenue At Lyndhurst | 1.6 mi | ★★★★★ | 35 | 0 |
| Heritage Healthcare Of Lyndhurst | 2.2 mi | ★★★★★ | 0 | 0 |
| Mount Saint Joseph Rehab Center | 2.3 mi | ★★★★★ | 0 | 0 |
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