Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Richland Post Acute during CMS and state inspections, most recent first.
A resident with complex medical needs was observed by staff and a representative to be slumped over, unresponsive, and weak, but nursing staff did not perform an assessment or obtain vital signs before the resident was sent to a medical appointment. At the clinic, the resident was found to be in shock and required emergency intervention. The DON confirmed that an immediate assessment should have been performed when a change in condition was noted.
Two residents experienced significant delays in receiving their meal trays during multiple meal services, resulting in them waiting and eating alone after others had finished. Staff interviews confirmed that meal trays were sometimes misplaced due to changes in dining location preferences, leading to undignified dining experiences.
The facility did not ensure accurate completion and validation of PASRR screenings for three residents with mental health diagnoses, resulting in missing documentation of conditions such as major depressive disorder, anxiety, and PTSD, and failure to initiate required Level II referrals. Staff interviews confirmed that PASRR reviews were not consistently thorough, and necessary follow-up actions were not taken.
The facility did not develop baseline care plans within 48 hours of admission for several residents, omitting required elements such as resident-specific goals, physician and dietary orders, therapy, social services, and PASRR documentation. Staff interviews revealed a lack of awareness of these requirements, and residents did not receive written summaries of their care plans or medication reviews upon admission.
Three residents did not have comprehensive, individualized care plans addressing their specific needs and diagnoses, including tobacco use, trauma history, and major medical conditions. Staff confirmed that required care plan elements such as mood, behavior, diagnoses, and risk factors were missing or incomplete.
Three cognitively intact residents were not properly informed about the binding arbitration agreement, including their right to refuse to sign and the 30-day cancellation period. Staff interviews revealed inconsistencies in how the ADR was explained, with some staff not clearly distinguishing the ADR from other admission paperwork or failing to communicate residents' rights regarding the agreement.
A resident with a tracheostomy did not have required emergency equipment, such as an obturator and Ambu bag, immediately accessible at the bedside. Nursing staff failed to comprehensively assess or document the resident's ability to perform tracheostomy care, and staff had not completed necessary training or competencies for tracheostomy care and emergency interventions. The care plan lacked specific goals and interventions for the resident's tracheostomy care, and documentation did not accurately reflect the care provided.
Expired medications and biologicals, including supplements, pain relievers, and glucose control solutions, were found stored in the medication room, with both partial and full bottles mixed together. Staff interviews revealed no clear assignment for checking and disposing of expired items, and oversight processes were not being followed as required by facility policy.
Two residents were not offered influenza or pneumococcal immunizations, nor was there documentation that education on the risks and benefits was provided. Staff interviews confirmed that while the process required offering immunizations and documenting consent or declination, these steps were not documented in the medical records for the affected residents.
The facility did not ensure that an LPN completed required training in communication, resident rights, abuse prevention, infection control, compliance, and QAPI before providing care, and two RNs lacked documentation of annual QAPI training. Review of staff records and interviews confirmed these training deficiencies, contrary to facility policy and regulatory requirements.
A resident with Parkinson's and severe cognitive loss, requiring two staff for transfers, experienced a fall when a single nursing assistant attempted to transfer them alone. The facility failed to report this incident of neglect to the state agency within the required timeframe, as the administrator did not recognize it as neglect. This was a repeat deficiency.
A resident with Parkinson's disease and severe cognitive loss, requiring two staff for transfers, fell when a NA attempted a solo transfer without a gait belt, contrary to the care plan and facility policy. Miscommunication among staff and disregard for the spouse's warning contributed to the incident, highlighting a deficiency in supervision and care practices.
The facility failed to develop effective discharge plans for two residents, one with severe cognitive impairment and another with intact cognition, both desiring to return to the community. Despite their needs and goals, the care plans lacked comprehensive discharge planning, including goals, needs, and potential discharge locations. This oversight placed the residents at risk for decreased self-worth and dissatisfaction.
A resident with severe cognitive impairment developed avoidable pressure injuries due to the facility's failure to consistently provide ordered wound treatments, perform skin assessments, and implement necessary equipment. The resident's lower extremity was not properly positioned, and staff were not trained on the use of positioning devices. Scheduling conflicts with wound care providers and lack of follow-up on medical orders contributed to the worsening of the resident's condition.
The facility failed to ensure accurate completion of PASARR for residents with serious mental illness (SMI), leading to deficiencies in the assessment process. A resident with depression and anxiety did not receive a required Level II evaluation, while another with anxiety was not accurately assessed in the PASARR. Staff interviews revealed inconsistencies in the admissions process, resulting in incomplete evaluations for residents with SMI.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, including those with recent falls, fractures, and cognitive impairments. Interviews and record reviews revealed that residents and their representatives were not provided with initial goals or treatment plans, and essential information was missing from the documents used as care plans. This deficiency placed residents at risk of unmet care needs.
The facility failed to ensure residents were free from unnecessary psychotropic medications, affecting three residents. One resident received medications without an AIMS assessment or behavior monitoring. Another was given Ativan without non-pharmacological interventions or behavior tracking. A third resident was administered Olanzapine without monitoring for specific behaviors, despite care plan requirements.
A resident with a coccyx fracture and heart failure reported feeling afraid of a male LPN who allegedly singled them out for requesting pain medication. Despite the facility's decision to remove the LPN from the resident's care, the LPN continued to interact with the resident, causing discomfort and fear. The facility's failure to effectively communicate and enforce protective measures placed the resident at risk.
The facility failed to report abuse and elopement incidents involving two residents to the State Agency. One resident, with moderately intact cognition, was threatened by a roommate with scissors, but the incident was not logged or reported. Another resident, with impaired cognition, experienced multiple elopement incidents, including exiting through a door with a malfunctioning alarm, which were logged but not reported. The facility's communication and reporting procedures were inadequate, as acknowledged by staff.
The facility failed to investigate an abuse allegation involving a resident who reported being threatened by their roommate with scissors. The grievance form was incomplete, and the administrator was unaware of the incident. Additionally, another resident eloped despite wearing a wander guard, and the facility did not reassess their elopement risk or report the incidents to the State Agency in a timely manner.
The facility failed to create comprehensive care plans for two residents, one with cancer and another with a persistent rash. The care plans did not address all medical conditions or provide specific interventions, leading to unmet care needs. Staff interviews revealed a lack of communication and updates to the residents' care plans.
A resident with dermatitis and a tailbone fracture reported ongoing irritation under their breasts, but the facility failed to obtain a new treatment order after the previous Nystatin powder order expired. Despite the resident's complaints and visible skin irritation, the LPN documented no new skin issues and did not discuss the rash with the provider, contrary to the facility's expectations for skin assessments.
A resident with vascular dementia and other conditions was inadequately supervised, leading to multiple elopement incidents. Despite wearing a wander guard, the facility's alarm system failed to alert staff, and the resident's care plan was not promptly updated. Staff interviews revealed inconsistencies in monitoring and documentation, and the facility did not report the incidents to the state agency.
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in equipment cleanliness and lack of medical orders. A resident with COPD had a nebulizer and oxygen concentrator with tubing not stored cleanly, and no medical orders for oxygen therapy or equipment maintenance. Another resident's nebulizer equipment was not cleaned or stored properly. Staff interviews confirmed non-compliance with expected procedures, placing residents at risk for unmet respiratory needs.
A resident with end-stage kidney disease and diabetes did not receive consistent dialysis care, as morning medications and blood sugar monitoring were missed on multiple occasions, particularly on dialysis days. Facility staff were unaware of the issue, and there was a lack of communication with the dialysis facility.
A resident with PTSD experienced a traumatic event when a male resident with dementia entered their room at night, causing distress. The facility failed to assess or monitor the resident's PTSD, and no interventions were in place to address this diagnosis. The resident felt unsupported and anxious, as staff did not follow up or implement preventive measures.
A facility failed to ensure that a medical provider reviewed and completed recommendations from a Pharmacist's monthly medication review for a resident with dementia, anxiety, and depression. The resident was prescribed sertraline and trazodone, leading to potential duplicate therapy. The provider did not respond to recommendations in May and July, and although the June recommendation was declined, no written rationale was provided. The Interim DON was unaware of the incomplete documentation.
The facility failed to properly label and store food items, with undated syrup containers in dry storage and unsanitary conditions in the communal nutritional refrigerator. The refrigerator contained undated food items and was not cleaned regularly, posing a risk of contamination.
The facility failed to implement proper infection control measures, including hand hygiene and glove changes during resident care, and lacked adequate Legionella testing protocols in their water management program. Observations showed staff did not change gloves or perform hand hygiene after cleaning residents, and the facility's water management plan lacked specific testing protocols and corrective actions. These deficiencies increased the risk of exposure to infectious diseases.
The facility's laundry room was found to be unsanitary due to a leaking washing machine, which had been an issue for months. The Housekeeping/Laundry Director noted soaked towels and sludge oozing from the laminate floor, indicating unsanitary conditions. The Maintenance Director confirmed awareness of the problem and planned to address it.
A resident with end-stage renal disease and dementia did not receive proper hemodialysis care due to the facility's failure to remove the pressure dressing from the resident's fistula after dialysis, despite repeated instructions from the dialysis center. The facility's staff did not consistently monitor the resident's condition or adhere to the policy, leading to a lack of proper assessment and post-dialysis evaluations.
A resident with multiple diagnoses exhibited significant changes in condition, including confusion and left-sided drooping. Despite reports from caregivers, the facility staff delayed sending the resident to the ER, leading to a diagnosis of respiratory failure and TIA.
Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to identify and assess a significant change in condition for a resident with multiple complex diagnoses, including an upper arm fracture, pancreatic cancer, and diabetes. On the day in question, the resident was noted by staff and the resident's representative to be slumped over in a wheelchair, difficult to arouse, and unresponsive to voice or visual commands. Despite these observations, no immediate assessment or vital signs were obtained by nursing staff, and the resident was not evaluated further before being sent to a scheduled medical appointment. Staff interviews revealed that both a nursing assistant and a registered nurse observed the resident's altered state, including increased sleepiness and physical weakness, but did not initiate a nursing assessment or notify a provider. The nurse stated that documentation was only required by exception and did not consider the resident's sleepiness as an indication for further assessment, relying on earlier normal vital signs. The resident was subsequently transported to a medical appointment in a compromised state, with staff at the clinic immediately recognizing the severity of the condition and calling emergency services. Emergency medical services documented extremely low blood pressure and altered level of consciousness, and the resident was admitted to the hospital in shock. The Director of Nursing confirmed that staff should have performed an immediate assessment and obtained vital signs when a resident appeared different. The failure to assess and respond to the resident's change in condition resulted in a missed opportunity to evaluate and treat a potentially life-threatening situation.
Failure to Provide Timely and Dignified Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents by not serving their meals in a timely manner during multiple observed meal services. One resident, who was cognitively intact and required minimal assistance, waited 36 minutes for their dinner tray after all other residents had been served, and was observed sitting without food while others ate and finished their meals. The resident reported that this was not an unusual occurrence and that their meal tray had been misplaced on a hall cart. During a subsequent lunch, the same resident again did not receive their tray until after all others had been served, with staff confirming the tray was found on a hall cart. Another resident, recently admitted with a history of stroke and acute hemolytic anemia, also experienced a significant delay in receiving their breakfast tray, waiting 33 minutes after meal service began. This resident was observed watching others eat and requested food from staff before their tray was finally delivered, after others at their table had finished and left. Staff interviews confirmed that meal trays were sometimes misplaced due to residents changing their preferred dining locations, resulting in delays and residents being left without meals while others ate.
Failure to Accurately Complete PASRR Screenings and Referrals
Penalty
Summary
The facility failed to properly review and validate the accuracy of Preadmission Screening and Resident Reviews (PASRR) for residents with mental disorders or intellectual disabilities. For three residents, the PASRR Level I screenings did not accurately reflect their mental health diagnoses, and required Level II referrals were not completed when indicated. Specifically, one resident was admitted with diagnoses of dementia, major depressive disorder (MDD), and anxiety, but their Level I PASRR did not document the MDD or anxiety, and no Level II referral was made. Another resident with depression had a Level I PASRR indicating a mood disorder, which should have triggered a Level II referral, but no such referral was found in the record. A third resident with depression, anxiety, and PTSD had a PASRR that did not document the PTSD diagnosis. Staff interviews revealed that the admissions and social services staff were responsible for reviewing PASRRs for accuracy but failed to identify or correct these omissions prior to or after admission. In some cases, staff relied on the hospital to provide accurate PASRRs and did not ensure corrections were made before residents were admitted. These failures resulted in incomplete PASRR documentation and the absence of required Level II referrals for residents with significant mental health diagnoses.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for seven out of seventeen residents reviewed. The BCPs were missing required components such as resident-specific goals, physician orders, dietary orders, therapy services, social service needs, and documentation of the Preadmission Screening and Resident Review (PASRR). Additionally, the facility did not provide a written summary of the BCP to the residents or their representatives, nor did they document the provision of this summary in the medical record as required by facility policy. Specific examples included residents with complex medical histories such as cellulitis, diabetes, depression, bipolar disorder, PTSD, heart complications, tracheostomy care, pressure ulcers, end-stage renal disease, dementia, and stroke. For these residents, the medical records and care plans reviewed showed that the required BCP components were not developed or documented within the mandated 48-hour timeframe. In some cases, residents reported not receiving a written care plan or a review of their medications upon admission, which led to confusion and unanswered questions about their care. Interviews with staff revealed a lack of awareness regarding the requirements for BCP development within 48 hours. Staff members stated that initial care plans focused only on basic activities of daily living and did not include other mandated elements such as initial goals, physician orders, therapy, or social services information. The Assistant Regional Director for Clinical Services confirmed that BCPs had not been developed for the identified residents within the required timeframe.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by policy. For one resident with dementia, diabetes, depression, and anxiety, the care plan did not address their ongoing use of chewing tobacco, despite documentation in their social history and direct observation of tobacco use at the bedside. Staff interviews confirmed that tobacco use was not identified or addressed in the care plan for this resident. Another resident with metabolic encephalopathy, joint replacement aftercare, and dementia had no care plan areas identified for their diagnoses, medications, nutrition, pain, fall risk, or mood and behavior, despite requiring substantial assistance and having severely impaired cognition. A third resident, admitted with a stomach wound, asthma, PTSD, and heart complications, had a positive trauma history but no care plan development regarding PTSD or their traumatic experiences. Staff interviews confirmed that care plans were expected to be comprehensive and individualized, but these requirements were not met for the residents reviewed.
Failure to Properly Explain Arbitration Agreement and Resident Rights
Penalty
Summary
The facility failed to adequately explain the binding arbitration agreement (ADR) to residents or their representatives, including the right to refuse to sign and the right to cancel the agreement within 30 days, as required. For three residents reviewed, all of whom were cognitively intact and required varying levels of assistance with activities of daily living, the ADR was either not explained in detail, not presented as optional, or the residents were unaware of their right to cancel within 30 days. One resident reported feeling that signing the ADR was a condition of admission, while another stated they were not told about the cancellation option, and a third was unaware they had signed the ADR at all. Staff interviews revealed inconsistencies in the admissions process. The Admissions Director stated that all forms, including the ADR, were reviewed with residents or their representatives, and that the option to not sign and the cancellation period were explained. However, another staff member involved in admissions indicated they explained the ADR as a way to use arbitration instead of litigation, but only mentioned a 30-day cancellation period in relation to admission paperwork, not specifically the ADR. The Administrator confirmed the ADR was not a condition of admission and that staff had been trained on the process, but was unsure why residents felt the ADR was not explained.
Failure to Provide Safe and Appropriate Tracheostomy Care and Emergency Preparedness
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice for a resident with a tracheostomy. Specifically, the required emergent tracheostomy tube equipment, such as an obturator and Ambu bag, was not immediately accessible at the resident's bedside. Observations confirmed that these items were missing from the resident's room, and staff interviews revealed uncertainty about when the equipment was placed at the bedside. Additionally, the facility's policies lacked clear guidance on the required emergency equipment and staff training for respiratory emergencies. Nursing staff did not comprehensively assess or document the resident's tracheostomy care. The resident's medical record and care plan did not include a thorough evaluation of the resident's ability to perform self-care for the tracheostomy or specify the level of staff supervision required. Documentation inconsistencies were noted, with staff charting that tracheostomy care was completed or supervised, despite interviews indicating that the resident was not performing their own care and that staff had not actually completed the care. The care plan lacked resident-specific goals and interventions related to tracheostomy care. Furthermore, nursing staff had not completed the required training or competencies for tracheostomy care and emergency interventions. Interviews with facility leadership and staff confirmed that training and competency assessments had not been conducted for those responsible for the resident's care. The facility's own assessment identified the need for such training, but it was not implemented. These failures were observed in the context of a resident with significant medical needs, including long-term respiratory failure, cerebral palsy, asthma, and obstructive sleep apnea, who required substantial assistance with daily activities and tracheostomy care.
Expired Medications and Supplies Not Removed from Medication Room
Penalty
Summary
The facility failed to ensure that expired medications and biologicals were properly disposed of in the medication room, as required by facility policy and professional standards. During an observation, multiple expired items were found, including blood collection needles, various supplements (multivitamins, magnesium with calcium, vitamin D, vitamin E, iron), non-steroidal pain relievers, allergy medications, oral pain relief gel, moisture mouth gel, dairy lactase enzyme supplements, and a glucose control solution kit. Some of these items had been expired for several months, and both partial and full bottles were stored together, contrary to best practices. Interviews with staff revealed a lack of clarity regarding responsibility for checking and removing expired medications. One LPN stated that expired medications should not have been stored with non-expired ones and that there was no assigned person to routinely check for expired items. The administrator confirmed that oversight should be provided by the Director of Nursing Services and that a process should exist for nurses to perform regular checks and dispose of expired medications, but this process was not being followed.
Failure to Offer and Document Flu and Pneumonia Vaccinations and Education
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were offered and that education on the risks and benefits of these immunizations was provided to two out of five residents reviewed for immunization and infection control. For one resident with a history of stroke, immunodeficiency, and anxiety, the medical record showed no evidence that either immunization was offered or that any education regarding the risks and benefits was provided. The resident also did not recall any discussion about immunizations. For another resident with diagnoses including urinary tract infection, malnutrition, and repeated falls, there was no documentation that a pneumococcal immunization was offered or that education on risks and benefits was provided to the resident or their representative. Interviews with staff, including the Infection Control Nurse and the Director of Nursing Services, confirmed that the process was to review immunizations upon admission, offer them, provide education, and document consent or declination. However, in these two cases, there was no documentation in the medical records to support that these steps were completed. Both residents did not recall any previous conversations regarding immunizations, and staff acknowledged the lack of documentation.
Failure to Ensure Required Staff Training and Documentation
Penalty
Summary
The facility failed to implement and maintain an effective training program for both new and existing staff, as required by their own policy and state regulations. Specifically, one LPN did not have documentation of completed training in areas such as effective communication, resident rights and facility responsibilities, abuse/neglect and dementia management regarding abuse prevention, infection prevention and control, compliance and ethics, and QAPI prior to independently providing services. Additionally, two RNs did not have documentation of required annual QAPI training. These deficiencies were identified through interviews and review of staff records and training logs, which showed missing or incomplete training documentation for the staff reviewed. The facility's policy required job-specific training tailored to the resident population and compliance with federal and state mandates, as well as use of the facility assessment to guide training needs. Despite this, the review of personnel files and electronic training records revealed gaps in required training for both new and existing staff. The administrator acknowledged the missing documentation and indicated that a better process for tracking and documenting training would be established in the future.
Failure to Report Neglect Incident Involving Resident Fall
Penalty
Summary
The facility failed to report an incident of neglect involving a fall to the State agency as required. The incident involved a resident with Parkinson's disease and severe cognitive loss, who was admitted to the facility and required two staff members for assistance with transfers and toileting. On a specific date, the resident experienced a witnessed assisted fall while being transferred from their bed to a wheelchair by a single nursing assistant, despite the care plan indicating the need for two staff members. The nursing assistant was not strong enough to hold the resident, resulting in the fall, although the resident did not sustain any injuries. The facility's policy mandates that incidents of neglect, even those not involving abuse or serious injury, must be reported to the state survey agency within 24 hours. However, the administrator did not report the incident, as they did not perceive it as neglect. This oversight was identified during a review of the facility's investigation report and was noted as a repeat deficiency from a previous statement of deficiencies.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and care according to the resident's plan of care and facility policy, resulting in a fall incident involving a resident with Parkinson's disease and severe cognitive loss. The resident, who was at high risk for falls, required assistance from two staff members for transfers and toileting, as outlined in their care plan. However, on the day of the incident, a Nursing Assistant (NA) attempted to transfer the resident alone without using a gait belt, contrary to the facility's Gait Belt Policy. This action led to the resident's knees buckling and the NA guiding them to the floor, although no injuries were sustained. The incident was further compounded by a miscommunication between staff members, as Staff A had been informed by the day shift NA that the resident required only one staff member for transfers with a gait belt. Additionally, the resident's spouse, who was present during the incident, had informed Staff A that the resident required two staff for transfers, as indicated on the care directives inside the resident's closet door. Despite this, Staff A proceeded with the transfer by grabbing the resident's sweat pants, leading to the fall. The failure to adhere to the resident's care plan and facility policy placed the resident at risk for injury and highlighted a deficiency in the facility's supervision and care practices.
Failure in Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, which did not address their goals and needs. Resident 1, who had severe cognitive impairment and required substantial assistance for activities of daily living, was admitted with conditions including respiratory failure, heart disease, and kidney disease. Despite the resident's goal to return to the community, the care plan lacked documentation of a comprehensive, person-centered discharge plan, including discharge goals, needs, barriers, or potential discharge location. Resident 1 eventually discharged to home against medical advice without a documented discharge plan. Similarly, Resident 2, who had intact cognition and required partial assistance for activities of daily living, was admitted with heart failure, pneumonia, and kidney failure. The resident expressed a desire to discharge to the community, but the care plan also lacked a comprehensive discharge plan. Staff B, the Social Services Director, acknowledged the responsibility to ensure discharge plans were included in the care plans but failed to do so for both residents. The absence of a documented discharge plan for these residents placed them at risk for decreased self-worth and dissatisfaction with their living situation.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to prevent the development and worsening of a pressure injury for Resident 23, who was admitted without any pressure injuries. The resident, who had severe cognitive impairment and required assistance for all activities of daily living, developed a pressure injury that was not present upon admission. The facility did not consistently provide ordered wound treatments, perform or document skin assessments, or obtain and implement necessary Durable Medical Equipment (DME) as ordered. Observations revealed that the resident's left lower extremity was not properly positioned, and the Podus boot phalange was not used to maintain the correct position, contributing to the development of pressure injuries. The resident's medical record showed orders for decubitus precautions and a Podus boot with a side phalange to prevent rotation of the left lower extremity. However, these orders were not consistently followed, and the care plan lacked directives for positioning the lower extremity or updates for current skin integrity status. The Treatment Administration Record indicated multiple missed treatment opportunities for the resident's pressure injuries, and there was a lack of documentation regarding skin checks under the brace. Staff interviews revealed that nursing assistants were not trained on the proper use of the Podus boot phalange or the correct positioning of the resident's leg. The facility's contracted wound care provider was unable to see the resident due to scheduling conflicts with the resident's dialysis treatments. Attempts to refer the resident to an outside wound provider were unsuccessful due to issues with medical coverage and scheduling. The resident's pressure injuries worsened over time, with assessments indicating the need for surgical debridement. Despite the resident's representative's request for a second opinion, the facility did not obtain the necessary orthosis or follow up on the orthopedic surgeon's orders, further contributing to the resident's unmet care needs.
Deficiency in PASARR Completion for Residents with SMI
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Reviews (PASARR) were correctly completed for residents with serious mental illness (SMI) or intellectual/developmental disabilities upon admission. This deficiency was identified for four out of five residents reviewed. The PASARR process is crucial to ensure that individuals with SMI or developmental disabilities are not inappropriately placed in nursing homes without the necessary mental health care and services. The report highlights that the facility did not complete the required Level II PASARR evaluations for residents who had a positive Level I PASARR, indicating a potential need for further assessment. For Resident 43, the medical records showed diagnoses of depression and anxiety, which were marked as SMI indicators in the PASARR. However, no Level II referral was completed. Staff interviews revealed that the facility relied on hospitals to complete Level II evaluations before admission, but this process was not consistently followed. Similarly, Resident 5 had a diagnosis of anxiety and was prescribed Cymbalta, but the PASARR did not reflect this diagnosis, and no Level II evaluation was conducted. Staff involved in the admissions process acknowledged the oversight and the need for accurate PASARR completion. Resident 23's records showed diagnoses of depression, anxiety, and insomnia, with corresponding psychotropic medications prescribed. However, the PASARR did not list anxiety or insomnia as diagnoses, indicating a lack of thorough assessment. Resident 34 also had a diagnosis of anxiety and was prescribed Ativan, but the PASARR did not reflect this SMI disorder. Interviews with staff indicated that there was a process in place to review PASARRs for accuracy, but it was not effectively implemented, leading to these deficiencies.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan (BCP) within 48 hours of admission for three residents, which included specific initial goals and treatment plans. This deficiency was identified through interviews and record reviews. Resident 7, who was admitted with a recent fall and depression, did not receive a BCP within the required timeframe, leaving them unaware of their care plan. Similarly, Resident 58, admitted with multiple fractures and Chronic Obstructive Pulmonary Disease, did not have a BCP developed within 48 hours, and the resident was not provided with a summary of their initial goals, medications, or services. Staff interviews revealed that the BCP was not shared with the resident or their representative unless requested, and the Kardex used as a BCP lacked essential information. Resident 52, admitted with heart complications and vascular dementia, also did not have their BCP reviewed with their representative within 48 hours. The resident's representative confirmed that they had not discussed the BCP with staff shortly after admission. Staff interviews indicated that care plans were typically reviewed during care conferences, but not specifically within the 48-hour window required for BCPs. This lack of timely communication and documentation placed residents at risk of unmet care needs and a lack of understanding regarding their care plans.
Failure to Monitor and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, affecting three out of five residents reviewed. For Resident 23, the facility did not conduct an Abnormal Involuntary Movement Scale (AIMS) assessment since admission, nor did they monitor person-centered behaviors or sleep patterns to justify the use of psychotropic medications such as alprazolam, trazodone, and sertraline. This lack of monitoring and assessment placed the resident at risk of receiving unnecessary medications. Resident 34, who was admitted with a diagnosis of anxiety, was prescribed Ativan on an as-needed basis without any person-centered behavior monitoring or non-pharmacological interventions attempted prior to administration. Additionally, no AIMS assessment was completed before starting the psychotropic medication. The resident reported that their anxiety was related to their cancer diagnosis, but the facility did not update the care plan to reflect specific behaviors or interventions. For Resident 35, who was diagnosed with severe dementia and other behavioral disturbances, the facility administered Olanzapine without monitoring for specific behaviors as outlined in the care plan. Despite the care plan listing various behaviors to monitor, there was no documentation of such monitoring in the medication administration records. A pharmacy review also noted the absence of behavioral monitoring, indicating a failure to ensure the medication's necessity.
Failure to Protect Resident from Alleged Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from potential abuse and neglect after an allegation was made against a staff member. Resident 51, who was cognitively intact and experiencing frequent pain due to a coccyx fracture and heart failure, reported feeling afraid of a male staff member, identified as Staff F, a Licensed Practical Nurse. The resident alleged that Staff F was singling them out and judging them for requesting pain medication, leading the resident to feel the need to exaggerate their pain levels. Despite being informed of the allegation, Staff F continued to interact with Resident 51, including sitting on the resident's bed and discussing pain management, which made the resident uncomfortable and fearful. The facility's administration, represented by Staff A, was informed of the allegation and initiated an investigation, deciding that Staff F should be removed from providing care to Resident 51. However, this decision was not effectively communicated or enforced, as evidenced by Staff F's continued presence in Resident 51's room. Staff B, the Interim Director of Nursing Services, was unaware of the restriction and only removed Staff F from the resident's care after being informed of the situation. This lack of communication and enforcement of protective measures placed the resident at risk and demonstrated a failure to adequately address the reported concerns.
Failure to Report Abuse and Elopement Incidents
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Agency for two residents, which placed them at risk for unidentified and ongoing abuse or neglect. Resident 27, who had moderately intact cognition, reported that their former roommate threatened them with scissors. Despite informing staff, the incident was not logged in the facility's incident reporting log, and the grievance form initiated by a Registered Nurse was left incomplete. The facility administrator was unaware of the incident, indicating a lapse in communication and reporting procedures. Resident 52, who had impaired cognition and was unable to make sound decisions, experienced multiple elopement incidents. The resident was observed wandering the facility and exiting through a door with a malfunctioning alarm. Despite these incidents being logged, they were not reported to the State Agency. The Interim Director of Nursing Services acknowledged the incidents but had not completed the investigation, and the facility administrator did not report the incidents, correlating them instead with visits from friends and family.
Failure to Investigate Abuse Allegation and Prevent Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving Resident 27, who reported that their roommate, Resident 30, attempted to stab them with scissors during the night. Despite Resident 27 informing staff about the incident, the grievance form was left incomplete as Staff C was waiting for further information from Resident 27's representative. The facility's administrator, Staff A, was unaware of the incident and acknowledged that it should have been investigated as an allegation of abuse. Additionally, the facility failed to prevent an elopement involving Resident 52, who was observed wandering and exiting another resident's room. Despite wearing a wander guard, Resident 52 was able to open an exit door without triggering an alarm. The facility's incident reporting log showed previous elopement incidents, but Resident 52 was not reassessed for elopement risk until after a second incident. Staff A admitted that the elopement risk was not added to the resident's care plan in a timely manner and that the incidents were not reported to the State Agency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, leading to unmet care needs. Resident 34, who was admitted with metastatic breast and bone cancer, anxiety, elevated blood pressure, and other conditions, did not have a care plan addressing their cancer diagnosis or other medical conditions. Despite being treated for various conditions, there was no focus on their cancer treatment in the care plan. The resident expressed uncertainty about their treatment plan and discharge, indicating a lack of communication and updates from the facility. Resident 51, admitted with a fracture, heart failure, and dermatitis, also lacked a comprehensive care plan. The resident experienced a persistent rash under their breasts, which was not addressed in their care plan. The care plan did not specify the location of their pain or provide resident-specific interventions beyond medication. Staff interviews revealed a lack of communication and updates to the residents' care plans, with staff unaware of ongoing issues such as the rash. The facility's failure to update and communicate care plans left residents uninformed about their care and discharge plans.
Failure to Provide Skin Treatment for Resident's Rash
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an ongoing skin rash. The resident, who was admitted with a fracture to their tailbone and dermatitis, had intact cognition and reported irritation under their breasts. Despite having a previous order for Nystatin powder to be applied daily, the resident stated that the powder had not been applied for several days. Observations confirmed the presence of bright red, shiny skin under the resident's breasts, and two bottles of cornstarch powder were found in the resident's bathroom without labels to identify ownership. The facility's records showed that the order for Nystatin powder ended on July 5, 2024, and no new treatment orders were obtained for the rash. A Licensed Practical Nurse (LPN) documented a minus sign on the weekly skin assessment, indicating no new skin issues, despite the resident's complaints. The LPN admitted to not discussing the rash with the provider, even though the provider was present in the facility. The Interim Director of Nursing Services stated that the expectation was for thorough head-to-toe assessments and obtaining new treatment orders if new or worsening skin issues were identified.
Inadequate Supervision and Elopement Risk Management
Penalty
Summary
The facility failed to provide adequate supervision and safety monitoring for a resident identified as being at risk for elopement. The resident, who was admitted with vascular dementia, anxiety, depression, and seizures, was assessed as having a low risk for elopement despite exhibiting behaviors such as wandering and exit-seeking. The facility's interdisciplinary team meetings did not address these behaviors, and the resident's care plan was not updated following an elopement incident. The resident experienced multiple elopement incidents, including one where they exited through a window shortly after admission and another where they accessed the courtyard through an unalarmed door. Despite wearing a wander guard, the facility's alarm system failed to alert staff when the resident exited through certain doors. Observations showed the resident continued to wander into other residents' rooms and attempted to exit the facility without triggering alarms. Interviews with staff revealed inconsistencies in the monitoring and documentation of the wander guard system, as well as a lack of immediate care plan updates following elopement incidents. The facility's administrator acknowledged the elopement incidents but did not report them to the state agency. The courtyard gates remained unlocked due to fire egress requirements, further compromising the resident's safety.
Deficiency in Respiratory Care for Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in maintaining cleanliness and obtaining necessary medical orders. Resident 58, who was admitted with Chronic Obstructive Pulmonary Disease (COPD), had a nebulizer machine and oxygen concentrator with tubing that was not stored in a clean manner. Observations showed the nebulizer mask and tubing were left exposed on the nightstand, and the oxygen tubing was not contained in a bag, contrary to the facility's policy. Additionally, there were no medical orders for the use of oxygen therapy or maintenance of the equipment, and no pre/post assessments were conducted for the PRN nebulizer medication. Resident 5, who required assistance with daily living activities and was cognitively intact, also experienced similar issues with respiratory care. The resident's nebulizer mask and tubing were observed to be fully assembled and left on the nightstand without being stored in a bag. The resident reported receiving nebulizer treatments multiple times a day, yet the equipment was not properly cleaned or stored as per the facility's expectations. Staff interviews confirmed that the expected procedure for cleaning and storing the equipment was not followed. The facility's failure to adhere to its own policies and procedures for respiratory care placed these residents at risk for unmet respiratory needs. The lack of proper documentation and monitoring of respiratory equipment and treatments highlighted a significant oversight in the care provided to these residents. The deficiency was identified through observations, interviews, and record reviews, revealing a gap in the facility's compliance with professional standards of practice.
Inconsistent Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide consistent dialysis care and services for a resident with end-stage kidney disease and diabetes, leading to a deficiency in professional standards of practice. The resident, who had severely impaired cognition, was not administered morning medications, including insulin, nor were their blood sugar levels monitored prior to leaving for dialysis. This occurred on multiple occasions, as evidenced by the Medication Administration Record (MAR) and Diabetic Administration Record (DAR) reviews for June, July, and August 2024. The records showed significant lapses in medication administration and blood sugar monitoring, particularly on dialysis days, without any notification to the provider or dialysis facility. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's missed medications and monitoring. A registered nurse admitted to not administering medications or monitoring blood sugar levels because the resident left for dialysis early in the morning. The Licensed Practical Nurse/Resident Care Manager was unaware of the issue, and the Interim Director of Nursing Services acknowledged that the resident should have received their medications and monitoring as ordered. This deficiency placed the resident at risk for complications due to inconsistent medication administration.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as they did not assess or monitor the resident's past experiences or current triggers. The resident, who required minimal assistance for activities of daily living and had intact cognition, experienced a traumatic event when a male resident with dementia entered their room at night, causing significant distress. Despite the resident's history of PTSD from past traumatic events, the facility did not have any focus areas or interventions in the care plan to address this diagnosis. The social services assistant completed a trauma screen upon the resident's admission, but did not pursue further assessment when the resident declined to discuss past trauma. After the incident, the resident reported feeling uncared for and expressed ongoing fear and anxiety about the possibility of similar events occurring. The staff did not follow up with the resident to address their concerns or implement measures to prevent future occurrences, leaving the resident feeling unsupported and anxious until their discharge.
Failure to Address Pharmacist's Recommendations for Medication Review
Penalty
Summary
The facility failed to ensure that recommendations from the Pharmacist's monthly medication review were reviewed and appropriately completed by the medical provider for a resident reviewed for unnecessary medications. This deficiency involved Resident 23, who was admitted with diagnoses of dementia, anxiety, and depression. The resident's medication administration record showed orders for sertraline and trazodone, both used for treating depression, which could lead to duplicate therapy. The Pharmacist's reviews for May, June, and July 2024 included recommendations to review the use of these two anti-depressant medications together. The provider did not respond to the Pharmacist's recommendations in May and July 2024, and although the June 2024 recommendation was declined, the provider did not provide a written rationale for the decision, as required by regulation. During an interview, the Interim Director of Nursing Services stated that the expectation was for the Pharmacist's recommendations to be reviewed and completed in a timely manner, ideally within one week. However, they were unaware that the provider had not completed the required documentation for the June 2024 recommendation.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, as observed in the dry storage room and the nutritional refrigerator. In the dry storage room, several small containers of syrup were found on trays without any dates indicating expiration. This was acknowledged by the Dietary Director, who confirmed that the containers should have been dated. This oversight in labeling could lead to the use of expired or contaminated food products. Additionally, the nutritional refrigerator, which was communal and used by residents, staff, and families, was found to be unsanitary and contained undated or expired food items. Observations revealed large ice cream containers, popsicles, and fresh fruit containers without best by dates, as well as a dark brown substance and old food particles inside the refrigerator. The Dietary Director admitted that the refrigerator had not been maintained in a sanitary manner and that the responsibility for checking dates and cleaning fell to the evening shift cook. These failures in food storage and sanitation practices placed residents at risk for consuming contaminated or expired foods.
Infection Control Deficiencies in Hand Hygiene and Water Management
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically in hand hygiene and glove changes during resident care. Observations revealed that staff members did not change gloves or perform hand hygiene after cleaning a resident's bowel movement and before proceeding to other tasks, such as adjusting the resident's urinary catheter and bed linens. This was observed in the care of two residents, one of whom had a stage pressure injury and an indwelling urinary catheter, and the other with a fracture and dementia. Staff interviews confirmed that the correct procedures were not followed, and the staff acknowledged their lapses in infection control practices. Additionally, the facility did not have adequate Legionella testing protocols and procedures in place as part of their water management program. The facility's water management plan lacked specific testing protocols and corrective actions for when control measures were not met. Interviews with staff revealed a lack of awareness and documentation regarding the testing and monitoring of water sources for Legionella, as well as the absence of procedures to address control measures that were outside acceptable ranges. The facility's failure to adhere to infection control protocols and maintain a comprehensive water management plan placed residents at an increased risk of exposure to infectious diseases. The lack of proper hand hygiene and glove changes during resident care, coupled with insufficient Legionella testing and monitoring, highlighted significant deficiencies in the facility's infection prevention and control program.
Unsanitary Conditions in Laundry Room Due to Leaking Washing Machine
Penalty
Summary
The facility failed to maintain a functional, comfortable, and sanitary environment in the laundry room, which was observed to have unsanitary conditions. During an observation and interview, the Housekeeping/Laundry Director, Staff H, revealed that a washing machine had been leaking for a couple of months, resulting in soaked towels on the laminate floor surrounding the machine. The laminate floor was observed to squish down, and a grayish sludge oozed out from between the flooring, indicating unsanitary conditions. In a subsequent interview, the Maintenance Director, Staff G, confirmed that the washing machine had been leaking intermittently for months and acknowledged the unsanitary sludge issue, which they planned to address.
Failure to Remove Pressure Dressing Post-Dialysis
Penalty
Summary
The facility failed to provide appropriate hemodialysis care and services for a resident with end-stage renal disease and dementia, who required dialysis three times a week. The deficiency involved the failure to remove the pressure dressing from the resident's arteriovenous fistula after dialysis, as per the instructions provided by the dialysis center. Despite repeated notifications from the dialysis center staff to the facility, the pressure dressing was not removed, which was against the facility's policy and the physician's orders. The facility's policy required staff to assess the fistula site daily for signs of infection and to remove the pressure dressing within four hours post-dialysis. However, the staff failed to consistently monitor the resident's condition following dialysis and did not adhere to the policy. The dialysis center staff had communicated the issue multiple times to the facility, including writing instructions on the pressure dressing itself, but the problem persisted. Interviews with facility staff revealed a lack of awareness and follow-through regarding the removal of the pressure dressing. The Interim Director of Nursing was informed of the issue but did not ensure that the necessary education and actions were taken. As a result, the resident's fistula site was not properly assessed, and the post-dialysis evaluations were not consistently completed, placing the resident at risk for complications.
Failure to Timely Evaluate and Monitor Change of Condition
Penalty
Summary
The facility failed to timely and thoroughly evaluate and monitor a change of condition for a resident, leading to a delay in medical treatment. The resident, who had diagnoses including diabetes, respiratory disease, kidney disease, and heart disease, exhibited significant changes in condition on the morning of 04/19/2024. These changes included increased confusion, left-sided mouth drooping, and tremors. Despite these symptoms, the nursing staff did not promptly act on the resident's condition, leading to a delay in sending the resident to the emergency room for evaluation. On the morning of 04/19/2024, the resident's primary caregiver noticed the resident's confusion and inability to feed themselves, which was a significant change from their baseline. The caregiver reported these changes to multiple staff members, including a Registered Nurse and the Director of Nursing. However, the response was delayed, and the resident was not sent to the emergency room until later in the day. The Nurse Practitioner was consulted, and a urine test was performed, which came back negative for infection. Despite the resident's worsening condition, it took several hours before the decision was made to send the resident to the emergency room. Upon arrival at the emergency room, the resident was diagnosed with respiratory failure, tremors, and a transient ischemic attack (TIA). The emergency medical technicians who transported the resident noted significant symptoms consistent with a stroke, including slurred speech, left-sided drooping, and confusion. The delay in recognizing and acting on the resident's change in condition by the facility staff placed the resident at risk for a delay in medical treatment.
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 60 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Richland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Richland | 2.7 mi | ★★★★★ | 10 | 0 |
| Avalon Health & Rehabilitation Center - Pasco | 8.5 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of Kennewick | 9.5 mi | ★★★★★ | 38 | 0 |
| Regency Canyon Lakes Rehab And Nursing Center | 9.9 mi | ★★★★★ | 0 | 0 |
| Regency Hermiston Nursing & Rehab Center | 32 mi | ★★★★★ | 0 | 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.