The Villas at Richfield

Inspectors wroteBased on observation, interview, and document review the facility failed to provide a dignified dining experience for 1 of 1 resident (R87).

Inspectors wroteBased on observation, interview, and document review the facility failed to provide appropriate clothing (socks) to 1 of 1 resident (R96) who requested them.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure personal privacy during toileting for 1 of 1 residents (R71) reviewed for privacy.

Inspectors wroteBased on observation, interview, and document review the facility failed to offer or provide individual or group activities for 1 of 2 residents (R62).

Inspectors wroteBased on observation, interview and document review the facility failed to utilize available resources for 1 of 1 resident (R40) who requested eyeglasses.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure fall interventions were in place for 1 of 2 residents (R44) reviewed who were at risk for falls.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure nutritional supplements were provided as ordered for 1 of 1 resident (R74) reviewed who had nutritional supplements ordered.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff followed proper infection control practices for hand hygiene for 1 of 2 residents (R4) observed for personal cares.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive community safety assessment was completed to determine whether a resident could safely attend outside appointments independently and failed to maintain an effective system to account for and respond when residents did not return from outside appointments as expected for 1 of 1 residents (R1) who was unaccounted for overnight and required emergency department evaluation.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure care was provided in accordance with a resident's care plan for 1 of 3 residents (R18) reviewed for non-pressure related skin concerns.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were available for 1 of 1 resident (R16) reviewed for activities.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure bruises were adequately assessed and monitored for 1 of 1 resident (R92), failed to ensure non-pressure wounds had timely assessment and documentation for 1 of 3 residents (R92), and furthermore failed to implement and/or clarify a wound order after a hospitalization for 1 of 3 residents (R2) reviewed for non-pressure related wounds.

Inspectors wroteBased on observation, interview, and document review, the facility failed to appropriately assess and help maintain range of motion and prevent possible contracture who had limited functional movement in the right hand for 1 of 2 residents (R16) reviewed for range of motion (ROM).

Inspectors wroteBased on interview and document review, the facility failed to ensure timely reassessment after administration of as needed narcotic medication for 1 of 2 residents (R296) reviewed for pain.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 1 (R19) resident reviewed who had post-traumatic stress disorder (PTSD).

Inspectors wroteBased on observation, interview, and record review the facility failed the ensure residents were free from unnecessary medications for 1 of 2 residents (R25) reviewed for diuretic use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medical records were complete and accurately documented for 2 of 2 residents (R92, R25) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper placement of catheter bag for 1 of 1 resident (R2) reviewed for catheter use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the facility's survey results were kept in a location readily accessible to all residents and/or visitors who wished to review. This had the potential to affect all 97 residents and/or visitors.

Inspectors wroteBased on interview and document review, the facility failed to ensure alleged violations of an injury of unknown origin that resulted in suspicion of serious bodily injury were immediately reported, no later than 2 hours, to the State Agency (SA) and administrator for 1 of 1 resident (R2) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to thoroughly investigate an injury of unknown origin for 1 of 3 residents (R2), (R2 had a swollen, bruised, tender right wrist with no known related injuries or accidents) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure adequate and required information was communicated and documented to a receiving healthcare facility to provide continuity of care for 1 of 3 residents (R2) reviewed for discharge.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess, develop a plan of care, and provide interventions for 1 or 1 resident (R2) reviewed for catheter care. In addition, the facility failed to notify a provider for further direction when staff were unable to re-insert the catheter.

Inspectors wroteBased on interview and document review, the facility failed to develop a care plan to address diabetic management for 1 of 3 residents (R4) reviewed for nursing services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators, were labeled, dated and discarded properly. This deficient practice had the potential to affect 87 residents who received food and beverages from the refrigerators.

Inspectors wroteBased on observation, interview and document review, the facility failed to promote dignity while utilizing a mechanical lift sling for extended periods of time for 1 of 3 residents (R13) reviewed for dignity and who was dependent on staff for activities of daily living (ADL's) and required the use of a mechanical lift for transfers.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered safely for 3 of 3 residents (R79, R74, R354) who had medications left at the bedside and had not been assessed as safe to self-administer those medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure housekeeping services for a clean environment for 4 of 4 residents (R79, R2, R81, R19) with a shared bathroom.

Inspectors wroteBased on interview and document review, the facility failed to provide a care conference for 1 of 1 residents (R68) to review and revise care plan with the interdisciplinary team (IDT), who was reviewed for care planning. R68's quarterly Minimum Data Set (MDS) dated [DATE], identified R68 was cognitively intact and had diagnoses which included: malnutrition, anxiety and depression. R68's care plan revised 7/26/24, identified R68 was a vulnerable adult, was at risk for harm related to suicidal thoughts and had started working with relocation services to assist with finding housing. R68 was independent with transfers, ambulation, dressing, bathing, and personal hygiene. R68's Care Conference Form dated 4/1/24, identified it was a quarterly care conference, and resident and family was involved in plan of care. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 2 of 5 residents( R30, R12). In addition the facility failed to provide assistance with dressing for 1 of 5 residents (R66) reviewed for activities of daily living (ADL)'s.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 1 residents (R26) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 1 residents (R27) who were reviewed for call light accessibility.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide care and services to promote dignity for 2 of 3 residents (R1, R4) who required assistance with activities of daily living (ADLs) and reported feeling embarrassed by their hygiene appearance.

Inspectors wroteBased on interview and document review the facility failed to administer and discharge/assess timely a nebulizer treatment according to standards of for 1 of 1 resident (R2) who was left alone during administration of a nebulizer treatment for administration (15 minutes) and an additional 105 minutes following the treatment.

Inspectors wroteBased on observation, interview and document review the facility failed to have appropriate emergency equipment in the room and have complete tracheostomy care orders for 1 of 1 resident (R6) reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for 3 of 3 residents reviewed for comprehensive care plans when residents did not comply with their care planned smoking interventions.