Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission At Richfield Nursing And Rehabilitation during CMS and state inspections, most recent first.
Improper Brief Change Assistance Led to Resident Injury: A resident with COPD, morbid obesity, weakness, and reduced mobility required a 2-person total assist for transfers and brief changes, but a CNA changed the brief alone. During the brief change, the resident rolled out of bed using the grab bar, landed on her knees, and sustained a laceration and femur fracture. Records and staff notes showed the resident was dependent for multiple ADLs and had a care plan for impaired mobility and fall risk, while the RNC stated the resident would need 2 people if using a Hoyer lift and no documentation supported 1-person brief changes.
A resident with COPD, morbid obesity, weakness, and severe mobility impairment required 2-person total assist for transfers and brief changes, but during peri care the resident used a grab bar, rolled out of bed, and landed on her knees. Staff found a laceration with exposed adipose tissue, bruising, swelling, extreme pain, and the resident was sent to the ED with a femur fracture and laceration.
A resident with multiple chronic conditions, including MS and functional quadriplegia, required total assistance and scheduled colostomy care. Her colostomy bag failed and she waited about 30 minutes for help while staff attended to other residents. When staff returned, she was crying, in pain, and had redness in her groin and buttock areas. The MAR showed the colostomy was not changed until the next day, and no progress note documented the incident.
Improper Brief Change Assistance Led to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse, neglect, misappropriation of property, and exploitation when a Certified Nursing Assistant changed the resident’s brief alone even though the resident required an extensive two-person assist for brief changes. During that brief change, the resident rolled out of bed, landed on her knees, and sustained a laceration and femur fracture, which resulted in harm. The resident was identified as having chronic obstructive pulmonary disease, morbid obesity, generalized muscle weakness, muscle wasting and atrophy, difficulty walking, poor coordination, and reduced mobility. Record review showed the resident’s MDS indicated dependence for toileting, lower body dressing, personal hygiene, rolling left and right, sitting to lying, and lying to sitting, with dependent meaning the helper does all of the effort or assistance of two or more helpers was required. The care plan documented impaired physical mobility and fall risk, with interventions for supportive care, assistance with mobility as needed, and ensuring the call light and essential items were within reach. A nursing note dated 4/23/24 documented that the resident was a 2-person total assist for transfers with the Hoyer lift and for brief changes. On the day of the incident, staff were assisting with a brief change when the resident rolled herself onto her left side using the grab bar, over-turned, and rolled out of bed. Staff found the resident sitting against the bed, complaining of extreme pain and feeling light headed, with a laceration above the left knee, bruising and swelling to both knees, and a pool of blood on the floor. The resident was transferred by Hoyer lift to a gurney and sent to the emergency department, where she was admitted with a femur fracture and laceration. The Regional Nurse Consultant later stated that if the resident used a Hoyer lift, she would need two people for assistance, and that no documentation could be found showing the resident was only a 1-person assist with brief changes.
Failure to Prevent a Resident From Rolling Out of Bed During Brief Care
Penalty
Summary
The facility failed to ensure that a resident’s environment remained as free of accident hazards as possible and that adequate supervision and assistance devices were provided to prevent accidents. Resident 46 had diagnoses including COPD, morbid obesity, generalized muscle weakness, muscle wasting and atrophy, difficulty walking, and reduced mobility. The resident’s MDS showed dependence for toileting, lower body dressing, personal hygiene, rolling, and bed mobility, and the record documented that the resident required a 2-person total assist for transfers with a Hoyer lift and for brief changes. On the morning of the incident, staff were assisting Resident 46 with a brief change when the resident rolled onto her side using the grab bar, over-turned herself, and rolled out of bed. The resident landed on her knees while still holding the grab bar. Staff found a laceration above the left knee with exposed adipose tissue, bruising and swelling to both knees, and a pool of blood on the floor. The resident complained of extreme pain and feeling light headed, and EMS was called. The resident was transferred to the ED and was admitted with a femur fracture and a laceration. The record also showed that the resident had been documented as a 2-person total assist for brief changes and other care needs, yet the incident note stated that a CNA was providing peri care when the resident rolled out of bed. The facility’s documentation and interviews reflected that the resident used grab bars and required two people for Hoyer transfers, but the event occurred during a brief change when the resident was not kept from rolling out of bed and sustained harm.
Delayed Ostomy Care and Resident Distress
Penalty
Summary
Resident 48, who had diagnoses including progressive multiple sclerosis, COPD, kidney disease stage 4, chronic pain syndrome, edema, and functional quadriplegia, was dependent on staff for toileting hygiene and required total 2-person assistance with ADLs and lift transfers. Her care plan identified use of a colostomy, urostomy, and nephrostomy, with interventions to monitor and report pain or discomfort and to provide ostomy care every shift. A physician order directed colostomy care every shift, with wafer and bag changes every 3 days and as needed. On the day of the incident, the resident reported that her colostomy bag failed and that she was left sitting in bodily fluids for an extended period. Staff interviews documented that she asked for assistance with colostomy care and waited about 30 minutes before help was provided. Staff stated they were in the hallway and were taking other residents to the dining room when the resident requested assistance, and they did not return to check on her until 30 minutes had passed. When staff finally checked on the resident, she was crying, expressed pain, and redness was observed in her groin and buttock areas. The MAR showed the colostomy was not changed that day and was documented as changed the following day. No progress note was found about the incident. Interviews with the RAC, ADM, and DON confirmed the delay in care, the resident’s distress, and that staff believed other priorities took precedence over the resident’s needs.
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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 Richfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehenge Of Richfield | 0.4 mi | ★★★★★ | 0 | 0 |
| Mission At Community Living Rehabilitation Center | 27.2 mi | ★★★★★ | 0 | 0 |
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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 August 2026) and official state health department websites.