Richwood Nursing & Rehab

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure performance review evaluations were completed for every Certified Nursing Assistant (CNA) at least once every 12 months for 4 out of 4 CNA's personnel records reviewed, CNA 21, CNA 22, CNA 23, and CNA 24.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 33 sampled residents (Resident (R)16). Observation on 03/11/2025, 03/12/2025, and 03/13/2025 revealed multiple wheelchairs, wheelchair leg extenders and boxes observed on the other side of room from R16's bed.

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to send a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 sampled residents investigated for hospitalizations out of a total sample of 33 residents, (Resident (R)69 and R43). Review of R69's and R43's medical records revealed no documented evidence the facility provided notice of the residents' transfer to the hospital to the Office of the State Long-Term Care Ombudsman as required.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to implement the comprehensive person-centered care plan for 2 of 33 sampled residents (Resident (R)28 and R259). 1. On 12/09/2024 and 12/17/2024, R28 experienced a fall without injury, and the facility updated the resident's care plan with an intervention to educate staff to place dycem (a nonslip material used to stabilize objects) in the resident's wheelchair. 2. Additionally, the facility care planned R259 for one person assist with eating on 03/07/2025. Observation on 03/11/2025, 03/12/2025, and 03/13/2025 revealed however, R259 eating meals in her room without staff present to provide assistance.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to provide sufficient and timely activities of daily living (ADL) for 2 of 33 sampled residents who were unable to perform their ADLs (Resident (R)25 and R259). 1. The facility failed to assist R25 in maintaining his personal hygiene and comfort related to incontinence. R25 reported calling out for assistance for incontinence assistance; however, not receiving the assistance in a timely manner. He expressed feeling miserable after being left wet for as much as two hours at night and occasionally during the day. 2. Additionally, the facility assessed and care planned R259 for one person assist with eating on 03/07/2025. However, observation on 03/11/2025, 03/12/2025, and 03/13/2025 revealed no staff present in R259's room to assist the resident while she was eating her meals.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free from accidents as possible for 1 of 33 sampled residents, (Resident (R)28). The facility developed a care plan for R28's risk for falls which included an intervention for dycem (a nonstick material used to stabilize objects) to the resident's wheelchair on 11/08/2023. On 12/09/2024, R28 sustained a noninjury fall and the facility updated the resident's fall risk care plan on 12/09/2024, for staff to be educated to place dycem in her wheelchair. On 12/16/2024, R28 experienced another noninjury fall, and the facility updated R28's fall risk care plan on 12/17/2024, again with the intervention for staff to be educated on ensuring the dycem was in the resident's wheelchair.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents requiring respiratory care were provided such care consistent with professional standards of practice. Observation on 03/11/2025 and 03/12/2025 revealed R13's nasal cannula was not bagged while not in use.

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined that the facility failed to prevent accidents for one (Resident (R) 19) of twenty-two sampled residents. On [DATE], R19, whose mobility was per wheelchair, fell from the back of a transport van when staff released the safety restraints before assuring that the hydraulic lift was in place. R19 flipped backwards over her wheelchair, falling over 10 feet from the van onto the pavement, landing headfirst. R19 sustained actual harm, including a closed head injury, right and left rib fractures, and cervical spine strain as a result of the accident.

Inspectors wroteBased on observation, interview, record and policy review it was determined the facility failed to ensure two (2) out of the twenty-four (24) sampled residents, were able to obtain their personal funds on the weekends, Resident #91 and Resident #94.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective infection control program for the provision of a safe, sanitary, comfortable environment. Observation revealed clean resident clothing items transported on one (1) of two (2) units, Unit B, not covered to protect from dust and soil. In addition, one (1) of twenty-two (22) sampled resident's (Resident #79) nebulization mask was not stored in a sanitary manner, within a plastic covering.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to revise the care plan with interventions to secure the indwelling urinary catheter for one (1) of twenty-two (22) sampled residents, Resident #7. Observations revealed the resident's indwelling urinary catheter was not secured to reduce friction and movement at the insertion site.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents, Resident #7, received appropriate treatment and services for an indwelling urinary catheter. Observation of urinary catheter care for Resident #7 revealed staff failed to secure the indwelling urinary catheter to prevent trauma as required by the facility's policy.

Inspectors wroteBased on observation and interview, it was determined the facility failed to post a notice of the availability of the most recent survey results in areas prominent and accessible to the public.