Landmark of Richton Park Rehab & Nsg Ctr

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide tracheostomy care in accordance with physician orders, including the administration of oxygen, and failed to date and label oxygen tubing in accordance with facility policy and procedure. This affected three of three residents (R65, R11, and R85) reviewed for oxygen therapy in a sample of 54 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who smoke follow facility smoking policy. This deficiency has the potential to affect all 44 residents on the 3rd floor reviewed for Resident Rights.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were dependent on staff for showering and bed baths received those services for one of three residents (R2) reviewed for ADL assistance (Activity of Daily Living). Findings Include:On 5/13/2026 at 10:40am R2 was observed sitting on the side of his bed with a urine odor, soiled clothes and linen. On 5/13/2026 at 10:42am R2 said I have been asking the (Certified Nursing Assistant -CNA) could they please assist me with a bed bath and a change of clothes they say, yes and never return. On 5/13/2026 at 10:48am V4(Assistant Director of Nursing-ADON) said she will have R2 CNA come right away and assist him. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for one of three residents(R3) reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food substitutes offered to residents who declined the planned meal were of similar nutritive value to the original menu. This failure affected all 98 residents that consume food from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to cover the urinary catheter drainage bag for 1 (R2) resident. This failure affected one (R2) of three residents reviewed for urinary catheters.

Inspectors wroteBased on interview and record review, the facility failed to follow policy and procedure and failed to implement a valid PRN (as-needed) order for one resident (R2) receiving psychotropic medications, in accordance with federal regulations and facility policy. This failure affected one resident (R2) in a sample of three residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors and failed to follow their medication administration policies. These failures affected two residents (R2, R3) in a sample of three residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare/serve food in in manner that was palatable and attractive. This failure affected one resident (R3) reviewed for dietary services.

Inspectors wroteBased on interview and record review, the facility failed to follow physician order for STAT (Immediately) laboratory testing. This deficiency affected one (R8) of three residents reviewed for physician orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine Dental services. This deficiency affected one (R7) of three residents reviewed for dental services.

Inspectors wroteBased on interviews and records review, the facility failed to follow its guideline on Discharge/Transfers for one of one resident (R5) reviewed for transfers in a sample of 11 residents. On 2/10/26 R5 was sent out for an appointment. V27 (RN) stated that R5 arrived at the appointment location with no face sheet, physician order, or medication administration sheet. During an interview on 2/18/26 at 10:40am, V2 (Director of Nursing) stated that staff are aware of resident's appointments the day prior to the appointment and should have the paperwork ready on the day of the appointment. V2 stated that the facility's protocol is for a face sheet and a physician order sheet to be given to the transporter when a resident is picked up. During an interview on 2/17/26 at 4:30pm, V20 (RN, R5's night nurse) stated that she was not aware that R5 had an appointment. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its guideline policy for activities of daily living for one of one resident (R5) reviewed for activities of daily living in a sample of 11 residents. On 2/10/26 R5 was sent out for an appointment. V27 (RN) stated that R5 arrived at the appointment location unclean, unkempt and has not been changed for some time. During an interview on 2/18/26 at 10:40am, V2 (Director of Nursing) stated that she was informed by R5's family that R5 was sent for his appointment on 2/10/26 unclean. V2 stated that R5's night nurse informed her that she did not have time to get R5 ready for his appointment. V2 stated that staff are aware of appointments the day prior to the appointment and should have the resident ready on the day of the appointment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its colostomy care policy, resulting in a colostomy leak that led to potential skin irritation and infection. This applies to 2 of 2 residents (R3 and R8) reviewed for colostomy care in a sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its indwelling catheter and colostomy care policy, as evidenced by colostomy leakage and failure to maintain the urinary catheter bag and tubing below bladder level. This applies to 2 of 2 residents (R3 and R8) who were reviewed for infection control practices in a sample of 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a resident with services to avoid emotional distress and anguish by failing to assist a post-op patient with follow-up appointment, failed to ensure that resident was receiving therapy as ordered and failed to ensure that staff assist the resident with activities of daily living (ADL). These failures affected one (R3) of four residents reviewed for quality of care. As a result, R3 developed increased swelling, increased pain and blood clot to his right hip and stated that he feels hopeless since being admitted because he thinks nobody cares about his pain and healing process.

Inspectors wroteBased on observation interview and record review, the facility failed to manage post-op pain for one resident (R3) by failing to administer pain medications (Oxycodone and Tylenol) as ordered, failed to monitor and document effectiveness of pain relief, and failed to use non-pharmacological interventions as part of the pain control regimen as care planned. This failure affected one (R3) of four residents reviewed for pain management. These failures contributed to R3 suffering psychological harm and feeling a sense of hopeless because no one cared about his pain or healing and pain rated 10 on a scale of 1-10.

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff follow its medication administration policy by failing to sign the medication administration record, failed to ensure that staff properly reassess and document effectiveness of pain medication, and failed to properly account for the receipt and disposition of a psychotropic medication. This failure affected one (R3) of four residents reviewed for nursing care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was within reach and working properly for R2 who was diagnosed with a tracheostomy and uses a communication board for 1 of 3 (R2) residents reviewed for accommodation of needs in a total sample size of twelve. Findings Include:R2 was diagnosed with Acute Respiratory Failure with Hypoxia, Tracheostomy and Hemiplegia affecting the left non-dominant side. Minimal data set section B (hearing, speech and vision) dated 10/6/25 documents: Persistent vegetative state/no discernible consciousness. No. Speech Clarity: No speech. Care plan dated 11/11/25 documents: R2 uses the following appliances: Communication board, card or writing pad/board. On 12/3/25 at 1:11PM, R2's call light string was observed hanging from the wall, on the floor, with the pull switch in a down position. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not ensuring R7 was free from verbal abuse by V18 (nurse). This failure resulted in V18 engaging in a loud verbal abusive argument resulting in R7 feeling threatened and belittled like a child. In addition, the facility neglected to ensure V18 provided care according to professional standard for R2 and R12 who had the diagnosis of Respiratory Failure with attention to Tracheostomy by not providing suctioning as needed. This neglect resulted in R2 having difficulty breathing. R12 having low oxygen saturation of eighty percent (88%). V18 also neglected to administer R6's nightly prescribed long-acting insulin as scheduled for 4 of 4 residents reviewed for abuse in a total sample size of 12.

Inspectors wroteBased on interview and record review, the facility failed to follow their treatment/services to prevent/heal pressure and non-pressure wounds policy for one resident (R3) with multiple pressure sores by not following physician recommendations/orders for wound treatments, failing to document treatments administered and failing to document weekly measurements/assessments of wounds for one of three residents reviewed for wound care.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise R9 who was identified as high risk for elopement and moderate risk for wandering during a smoking break. This failure resulted in R9 climbing on top of a gazebo, jumping a fence, leaving the facility unauthorized without a pass, sleeping in an abandoned home with no utilities and on a train station platform for six days in cold inclement weather for one of one reviewed for supervision. Findings Include:R9 was admitted on [DATE] with the diagnosis of acute respiratory failure, pneumonia, asthma, hypertension, anemia and sleep apnea. R9 brief interview for mental status score documents 14/15 which indicates cognitively intact. R9's wander risk assessment dated [DATE] documents a score of ten (10) which indicate a moderate risk for wandering. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow up and follow through with obtaining a battery for a motorized wheelchair for a quadriplegic resident to ensure the resident can maintain his independence. This affected one of three (R1) residents reviewed for accommodation of needs. R1's face sheet shows diagnosis of diabetes, hypertension, chronic embolism, quadriplegia, history of traumatic brain injury, major depressive disorder, muscle wasting multiple sites, and fracture right leg. On 10/28/25 12:08pm R1 observed alert to person, place, and situation. R1 is observed resting in a Geri-chair in his room at the bedside. R1 said he can use his motorized wheelchair independently. R1 said the chair has been broke for a while. R1 said the aides have to take him around the facility. R1 said the aides take care of him. [...]

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to obtain physician orders for blood glucose monitoring/sliding scale insulin, failed to receive blood glucose parameters for physician notification, failed to follow physician orders, failed to ensure that medication was administered/documented within regulatory requirements, and/or failed to ensure that (critical) blood glucose levels were addressed by a physician/nurse practitioner for two of four residents reviewed for change in condition. These failures resulted in R1 sustaining critical blood glucose levels ranging from 413-500 (without intervention) for a total of 8 days within 1 month. These failures also resulted in R2 sustaining a critical blood glucose level of 400 (without prescribed sliding scale insulin) for 11 hours.

Inspectors wroteBased upon interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, and failed to notify the physician and responsible party regarding critical blood glucose levels for two of four residents (R1, R2) reviewed for change in condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to a resident who is at high risk for skin impairment. The facility failed to formulate wound/pressure care plan and implement LAL (Low air loss) mattress manufacturer's recommendation in prevention and management of wound care. These failures resulted R54 to develop DTI (Deep tissue injury) on right heel. This deficiency affects all five residents (R28, R36, R45, R54 and R59) in the sample of 17 reviewed for Wound/Pressure ulcer prevention and treatment management.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care and foot care to dependent resident. This deficiency affected all four (R36, R45, R54, and R59) residents in the sample of 17 reviewed for Activity of Daily Living (ADL) Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control practices for residents on enhanced barrier precaution and during ADL (Activity of Daily Living) care. This deficiency affects all four (R28, R47, R49 and R59) reviewed for Infection Control Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect and promote resident rights of a vulnerable resident. This deficiency affects one (R59) of three residents in the sample of 17 reviewed for Resident's right.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident call light is within reach. This deficiency affects 1 (R47) of 3 residents in the sample of 17 reviewed for Accommodation of needs.

Inspectors wroteBased on record review and interview the facility failed to submit for a PASRR level 11 (Preadmission screening resident review-PASRR) for 2 of 3 residents (R22 and R39) reviewed for PASRR level 11 in a sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow side rail physician order and care plan. The facility also failed to implement safety transfer to a dependent resident who is high risk for fall affecting 2 of 3 (R37, R59) residents reviewed for Accident Hazards in a total sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the gastrotomy tube placement was checked prior to administering medication for 1 of 1 resident (R49) reviewed for enteral feeding in a sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident refrigerators have recorded temperature log affecting 2 of 3 (R28, R29) residents reviewed for resident refrigerator in a sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy on posting direct care daily staffing numbers. This failure has the potential to affect 69 residents receiving care in the facility.

Inspectors wroteBased on interviews and records reviewed the facility failed to treat one resident with respect and dignity by placing him in the hallway tied to a wheelchair and having pictures taken. This failure affected one of one resident (R5) reviewed for dignity. Using the reasonable person concept it is reasonable to conclude that R5 felt cold, uncomfortable, and dehumanized when he was sitting in a wheelchair, in the hallway, with a sheet, no shoes, no socks.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their abuse policy to prevent unauthorized photos of a resident restrained to a wheel chair in the hallway. This affected one of three residents R5 reviewed for mental abuse. This failure resulted in R5 having unauthorized photos taken of him restrained to a wheelchair which is demeaning, and humiliating.

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure one resident was not physically restrained by being tied into a wheelchair with a gait belt and a bed sheet. This failure affects one of three residents (R5) reviewed for restraint use. This failure resulted in R5 having his freedom of movement inhibited and ongoing agitation, aggression, and anxiety. It is reasonable to conclude that R5 felt embarrassed and dehumanized.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their policy to report potential abuse violations to the abuse coordinator for one (R5) resident reported to be restrained, pictures were taken, and details of his care/condition were shared over the phone to unknown persons. This failure affected 1 of 3 residents reviewed. This failure resulted in perpetrator remaining with R5 to provide one on one care for the duration of his shift.

Inspectors wroteBased on interviews and records reviewed the facility failed to de-escalate a verbal altercation that escalated to physical altercation, R6 hit R7 with a cane. This affected 2 of 2 residents (R6, R7) reviewed for supervision.

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure a STAT order for a chest x-ray for new chest bruising was carried out within 4 hours. This affected one of one (R1) residents reviewed for radiology orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to discard potentially hazardous food (PHF) items by the use-by date. This failure has the potential to affect 15 residents who would receive the sandwiches from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure that a resident dignity is maintained for one of three (R90) observed for dignity in a sample of 20.

Inspectors wroteBased observation, interview and record review the facility failed to ensure clean resident room, bed, linens, and equipment are maintained. This deficiency affects one (R153) of three residents in the sample of 20 reviewed for providing Resident clean environment.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident is free from verbal and physical abuse from another resident. This deficiency affects one (R42) of three residents reviewed for resident-to-resident abuse in a sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to implement abuse prevention policy by failure to update Abuse assessment and formulate care plan after resident abuse incident occurred. This deficiency affects one (R81) of three residents in the sample of 20 reviewed for Abuse Prevention Program.

Inspectors wroteBased on interview and record review, the facility failed to perform pacemaker check as ordered and obtain a copy of hospice plan of care for two of four residents (R63, R66) reviewed for quality of care in a sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent worsening of acquired moisture associated skin disorder to resident who is at high risk for developing skin impairment. The facility also failed to follow up wound care physician recommendation. This deficiency affects one (R16) of three residents in the sample of 20 reviewed for Pressure ulcer prevention and treatment management.

Inspectors wroteBased on observation, interview and record review the facility failed to implement catheter care to resident with suprapubic catheter. This deficiency affects one (R153) of three residents reviewed for Catheter care management.

Inspectors wroteBased on observation, interview and record review the facility failed to follow up with pharmacy recommendation for physician response. This deficiency affects two (R16 and R63) of three residents in the sample for 20 reviewed for Pharmacy medication review.

Inspectors wroteBased on observation, interview and record review the facility failed to clean and cover a nebulizer mask after each use. This deficiency affects one (R16) of three residents in the sample of 20 reviewed for Infection control protocol.

Inspectors wroteBased on interview and record review, the facility failed to transmit assessments within 14 days of completion for three of three residents (R11, R43, R75) reviewed for resident assessment in a sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to prevent an incident of physical abuse during a resident to resident verbal altercation for one resident (R4) of five reviewed for abuse in a total sample of 11. This failure resulted in R4 being physically attacked by R5 suffering from a bruised face and bleeding from the mouth after being hit in the face by R5. Findings Include: R4 is a [AGE] year old with the following diagnosis: schizoaffective disorder, psychosis, post traumatic stress disorder, and subdural hematoma. R5 is a [AGE] year old with the following diagnosis: Alzheimer's disease. A Nursing note dated 1/13/23 documents around 2 AM the nursing staff responded to a call from R4. Upon arrival to the room, R5 was observed assaulting R4. A general assessment on R4 was remarkable for left lower eye bruising/swelling and minimal buccal bleeding. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform dressing changes as ordered by the wound physician for one resident (R6) of three reviewed for wound care in a total sample of 11. This failure resulted in R6's wound(s) declining by increasing in size on two separate occasions. Findings Include: R6 is a [AGE] year old with the following diagnosis: paraplegia, osteomyelitis, pressure ulcer of the sacral region stage four, pressure ulcer of the right buttocks stage four, and pressure ulcer of the right hip stage 4. On 3/5/24 at 3:13PM, R6 stated, there is one full time wound nurse (V13) and one part time wound nurse (V12). R6 stated V13 left the country for over a month and the only time R6's dressings would be changed was when V12 was in the facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their practice to confirm and follow physician orders to monitor blood glucose and administer insulin per sliding scale as prescribed for a resident diagnosed with type 2 diabetes with hyperglycemia. This affected one of three (R8) residents reviewed for physician orders. This failure resulted in 13 missed opportunities for blood sugar checks and 13 opportunities for insulin administration, R8 was sent to hospital, evaluated and treated for diabetic ketoacidosis, R8's blood glucose 658mg/dl.

Inspectors wroteBased on observation, interview and record review the facility failed to have an effective policy for contraband material to ensure that contraband is not brought into the facility. This affected two of two residents (R5 and R15), this failure resulted in R5 found unresponsive sent to hospital, tested positive for opioids on 9/6/23 and 10/31/23, R15 sent to hospital for chest pain and diagnosis with marijuana use.

Inspectors wroteBased on interviews and records reviewed the facility failed to offer an alternative plan to promote resident rights for independent residents with community passes and the facility failed to follow their policy for Outside Community Pass Privileges before preventing the residents with independent passes from leaving the facility. This failure has affected 21 residents out of 21 (R10-R14, and R16- R31) reviewed for independent passes.

Inspectors wroteBased on interviews and records reviewed the facility failed to develop individual care plan interventions to reflect residents' community pass status and to reassess residents for community passes if issues arise that compromise the residents' safety for 21 residents (R10-R14 and R16-R31) out of 21 reviewed for independent passes.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct daily skin assessment, follow physician's treatment orders and implement interventions in preventing the development and reopening of a pressure ulcer for two (R14 and R74) of four residents reviewed for pressure ulcers. This failure resulted in R14's healed pressure ulcer on the sacral area reopening and being classified as a facility acquired unstageable deep tissue injury and R74's intact skin developed a facility acquired Stage 3 pressure ulcer on the sacrum.

Inspectors wroteBased on interview and record review, the facility failed to adequately assess residents for a fall risk, failed to have appropriate fall interventions in place, failed to ensure that staff are familiar with residents fall risk status and fall interventions and failed to provide appropriate and sufficient supervision for residents assessed as requiring staff assistance and supervision for Activities of Daily Living (ADLs). This failure affected two ( R15 and R62) of 14 residents reviewed for falls. This failure resulted in R62 falling in her room, being sent to the hospital where she was found to have a left hip fracture and required a surgical procedure; this failure also resulted in R15 falling, while walking outside, in the facility's smoking patio, without the use of assistive device, which resulted in a left foot fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for providing dental care for residents by not identifying dental care needs and not ensuring dental services were provided for residents. This failure applies to four (R19, R27, R36, R55) of four residents reviewed for dental care and resulted in (R55) being hospitalized due to a dental infection and facial cellulitis.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse was working at least 7 days a week, 8 hours a day. This failure has the potential to affect all 104 residents currently residing in the facility reviewed for nursing care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not ensuring the kitchen environment and food preparation equipment was thoroughly cleaned, failed to ensure the food preparation area was free of personal equipment, and failed to wear hair restraints properly. This failure has the potential to affect all 105 residents currently in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedures for maintaining a clean environment by not ensuring resident's rooms are thoroughly cleaned, not ensuring resident's furnishings and medical care equipment are cleaned, maintained, and in good working condition, not ensuring residents clothing items are laundered as needed, and not ensuring shower rooms are thoroughly clean and in good repair. This failure applied to six residents (R10, R15, R19, R27, R36, R96) as well as the third floor shower room and has the potential to affect all 105 residents currently residing in the facility.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to follow its policy related to medication storage and labeling. This deficiency affected three (R41, R66, and R82) of three residents reviewed for medications and has the potential to affect the 55 residents currently residing on the third floor in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy related to medication self-administration for one (R13) of one resident reviewed for medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide community pass privileges to one of one resident (R302) reviewed for residents rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for providing assistance with activities of daily living by not ensuring dependent residents receive care and services to maintain good hygiene and grooming. This failure applied to three of three residents (R19, R27, and R69) reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedures for resident safety by not reporting and not investigating reports of unsafe resident behavior of drinking to intoxication in the facility. This failure applied to one of one resident (R36) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards while administering injectable medications. This failure applied to one (R30) of six residents reviewed for infection control during medication administration observation.