Richmond Center for Rehabilitation and Specialty H

Inspectors wroteBased on observation, record review and interviews the facility did not ensure a building elevator was maintained in a safe working condition. This was observed in 1 (Elevator #4) of 4 facility elevators. Specifically, residents and staff complained Elevator #4 was not in good working condition, and on 12/12/2025 at 12:28 PM, a staff was stuck inside Elevator #4 and was not able to get out of the elevator until staff came to assist them

Inspectors wroteBased on record review and interviews the facility failed to ensure resident's and/or resident's representative were afforded the right to participate in the care plan process. This was evident for two (2) of four (4) residents (Resident #348 and Resident #349) reviewed for Care Planning out of 37 residents. Specifically, Resident #349 and Resident #348's representative were not invited to participate in all of their care plan meetings.

Inspectors wroteBased on observations, record review and staff interviews conducted during the Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident on one (1) of seven (7) units (Unit 2 AB) in the neurobehavioral building. Specifically, resident's rooms were noted with broken and worn furniture, bed frames and legs with rust, discolored, streaked floors, television and dining room furniture in disrepair.

Inspectors wroteNumber of residents sampled: 4Number of residents cited: 1 Based on record reviews and interviews, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to meet a resident's need. This was evident of one (1) of four (4) residents (Resident #6) reviewed for Care Planning out of 38 sampled residents. Specifically, a comprehensive care plan for bowel management was not developed for Resident #6 who had a history of constipation.

Inspectors wroteNumber of residents sampled:6Number of residents cited:1 Based on observations, record review, and interviews, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. This was evident for one (1) of (six) 6 residents (Resident #184) reviewed during the Medication Administration task. Specifically, the functioning of the Gastrostomy tube was not verified prior to administration of medications to Resident #184.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure that food was served at an appetizing temperature during meal service. This was evident for one (1) of seven (7) neurobehavioral units (Unit 2 AB) out of total 13 units observed during Dining Observation. Specifically, food items served during lunch meal service were not maintained at palatable and appetizing temperatures.

Inspectors wroteBased on observations and interview, the facility did not ensure it provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evident for staff bathrooms and nurses station. Specifically, staff bathrooms and nursing stations were not maintained in a sanitary and comfortable manner.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00333922), the facility failed to ensure that a Resident received adequate supervision to prevent elopement. This was evident in one out of six residents sampled (Resident #1). Specifically, Resident #1, who was escorted by Home Health Aide #1, eloped from a clinic appointment on 02/20/24 at 12:35 am. Home Health Aide #1 stated that Resident #1 was a few steps behind them in the waiting room of the clinic and when they turned around Resident #1 was gone. Resident #1 was located on 02/27/24 and was transported to the hospital by Emergency Medical Service on 02/27/24 with diagnosis of alcohol withdrawal.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during kitchen observation. Specifically, the facility did not ensure that cold foods were stored at a temperature of 41 degrees Fahrenheit (F) and below, and the refrigerator temperature was not maintained at 41 F and below.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure garbage and refuse were disposed of properly. This was evident during kitchen observation. Specifically, the garbage compactor was observed without a lid or door to prevent the harboring and feeding of flies.

Inspectors wroteBased on interviews and record review conducted during the Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure residents' right to communicate with individuals and entities external to the facility. This was evident for 11 of 11 attendees of the Resident Council meeting. Specifically, the facility did not have a system in place for residents to receive and send mail on Saturdays.

Inspectors wroteBased on observation, interview, and record review during the Recertification survey conducted from 08/14/2023 to 08/21/2023, the facility did not ensure infection prevention and control practices were maintained. This was evident for 5 residents (Resident #336, #99, #155, #335, and #325) out of 38 total sampled residents. Specifically, 1) hand hygiene was not performed during tracheostomy care, 2) a Licensed Practical Nurse (LPN) was observed not donning Personal Protective Equipment (PPE) appropriately prior to entering the room of a resident on contact precautions for Candida Auris. In addition, blood sugar monitoring devices and insulin pen placed on surfaces in the resident's room were taken out of the room to be discarded/stored on the medication cart without being sanitized; [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 2 (Resident #225 and #166) of 35 total sampled residents. Specifically, 1) Resident #225 was fed by staff standing over them, and 2) Resident #166 was not provided with clothing to ensure they were dressed appropriately.

Inspectors wroteBased on observations, record review, and interview conducted during the Recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure the resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 4 (Residents #170, #327, #351, and #334) of 35 total sampled residnts. Specifically, 1) Resident #170's designated representative was not provided with a copy of the resident's BCP, 2) Resident #327 was not provided with a copy of their BCP, 3) Resident #351 was not provided with a copy of their BCP, and 4) Resident #334 was not provided with a copy of their BCP.

Inspectors wroteBased on record review and staff interviews conducted during the recertification survey conducted from 8/14/2023 to 8/21/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #351) of 1 resident reviewed for Dental out of 38 total sample residents. Specifically, there was no documented evidence that a CCP was developed and implemented for oral/dental concerns for a resident who was observed with missing teeth and poor dentition.

Inspectors wroteBased on observations, records review, and interviews during the Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure that a resident with a sacral pressure ulcer receive the necessary care and treatment to prevent infection of ulcer. Specifically, there was no dressing observed to the sacral area for a resident with a Stage Suspected Deep Tissue Injury pressure ulcer. This was evident for one (1) of three (3) resident reviewed for Pressure Ulcers out of 38 sampled residents. (Resident # 335). The finding is: Resident #335 was initially admitted with diagnoses that included Diabetes Mellitus, Necrotizing Fasciitis, and Gastrostomy status. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure a resident maintained acceptable parameters of nutritional status. This was evident for 1 (Resident #166) of 4 residents reviewed for nutrition out of 35 total sampled residents. Specifically, interventions to address Resident #166's significant weight loss were not implemented to prevent further weight loss.

Inspectors wroteBased on interviews, observations and record reviews conducted during a Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure timely identification and removal of expired medications. Specifically, expired medications were observed in the Emergency Medication Box on Unit 4.

Inspectors wroteBased on observations and staff interviews conducted during a Recertification survey conducted from 8/14/23 to 8/21/23, the facility did not ensure that all medications and biologicals were labeled properly and stored appropriately. Specifically, multiple bags of IV antibiotics were observed stored in a medication refrigerator without a thermometer, and one opened, undated vial of insulin was observed in the Medication cart. This was evident during observations conducted for the Medication Storage Task. (4th Floor)

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey the facility did not ensure that the resident meals were attractive, palatable, delivered timely and that the meal temperatures were at an appetizing temperature. Specifically: 1)Residents complained of food palatability, lack of attractiveness, missing items, and hot meals served cold. (Res #s 29, 211, 253, 296, 303, 305, 212, and 5) 2) During dining task plate waste was observed during lunch meal. (3A/3B ) 3 )Lunch Test trays checked were found to be below the appetizing temperature for resident (res) consumption, and food trucks arrived late on 3 of 13 units. (Neuro 2EF, 2CD, 4EF, 4K and 3A, 3B, & 4th floor) 4 )The Resident Council President (Resident #351) and resident council minutes verified ongoing complaints of cold food, late meals, and other food quality complaints. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure a residents representative was immediately notified of the need to alter treatment. Specifically, the Unit Nurse Manager did not inform a resident's family member when changes were made to the resident's psychotropic medication regimen. This was evident for 1 of 1 residents reviewed for Notification of Change (Resident #66). The finding is: Policy titled, Change in Condition Notification last reviewed 2/2021 documented the licensed nurse will notify the resident's next of kin/responsible person when a change in resident's medical or clinical treatment as identified by resident's Medical Doctor (MD). Resident #66 was diagnosed with respiratory failure with vent dependence and tracheostomy. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure that a resident's Comprehensive Care Plan (CCP) was person-centered and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the CCP related to cognition was not complete with individualized interventions to meet the resident's needs. This was evident for 1 of 36 sampled residents (Resident #66). The finding is: A facility policy titled Care Plans - Comprehensive was dated 10/2020 and documented care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, identify professional services responsible for each element of care, and updates the care plan at least quarterly. [...]

Inspectors wroteBased on record reviews and staff interviews conducted during a recertification survey (37JG11) completed on 6/30/2021, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, on 05/22/2021, Resident #313 had a fall and complained of left shoulder pain. The recommended left shoulder x-ray was not ordered and completed timely, and the resident was not diagnosed with a left clavicle fracture until 5/26/21, 4 days after the fall. This was evident for 1 of 4 residents reviewed for Accidents (Resident #313). The finding is: [...]

Inspectors wroteBased on observation, record review and interview conducted during the Recertification survey, the facility did not ensure that residents received necessary respiratory care consistent with professional standards of practice and the comprehensive care plan. Specifically, residents on oxygen therapy were receiving oxygen at the incorrect flow rate. This was evident for 2 of 6 residents reviewed for respiratory care out of a sample of 36 residents. Resident (#210 and 253).

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure drugs and biologicals were stored in accordance with professional principles and the manufacturer's specifications. Specifically, a medication refrigerator was observed with melting ice from the freezer causing water leakage and pooling in and around the medications stored there, and an insulin pen was stored directly underneath the freezer, which was encased in ice. This was evident for 1 of 2 medication rooms reviewed during the Medication Storage task (Floor 4-AB)

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure proper storage of residents' personal food items according to professional standards for food safety. Specifically, a pantry refrigerator was observed to have undated and unlabeled resident food items with no use by date; and, one container of a spoiled substance. This was evident for 1 of 13 Unit Pantries. (Unit 4B)

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey (37JG11) completed on 06/30/2021, the facility failed to ensure that infection control practices and procedures were maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) a Certified Nursing Assistant (CNA) #2 and Licensed Practical Nurse (LPN) #1 failed to perform required hand washing during a dressing change; and, 2) A Behavioral Health Specialist (BHS) #1 did not perform hand hygiene after resident care. This was evident for 1 of 2 residents reviewed for Pressure Ulcer (Resident #66) and 1 of 11 units (Unit - 2AB) observed for Infection Control.