RICHLAND, WA - A federal health inspection completed on August 12, 2024, at Richland Rehabilitation Center identified multiple care deficiencies, including a resident who developed avoidable pressure injuries requiring surgical intervention, repeated elopement incidents involving a cognitively impaired resident, and systematic failures in medication administration for a dialysis patient.
Resident Develops Serious Pressure Injuries Under Facility Care
The most significant finding involved a resident who was admitted to the facility in late May 2024 with an inoperable leg fracture, diabetes, and end-stage kidney disease. According to inspection records, the resident arrived without any pressure injuries but subsequently developed wounds on their left heel and outer knee that eventually required surgical debridement.
The inspection documented that the resident was provided with a Podus boot—a specialized device designed to suspend the heel and eliminate pressure while enhancing blood circulation for healing. However, surveyors observed on multiple occasions that staff failed to properly position the device's phalange, which functions to prevent the leg from rotating inward.
On August 5, 2024, surveyors observed the resident lying in bed with their left leg internally rotated, with the inner part of the leg lying flat on the bed despite the boot being in place. The phalange that should have maintained proper positioning "had not been used to maintain the LLE in an upward/correct position."
Two days later, surveyors documented that the resident had a gauze wound dressing dated August 4, 2024, that was "saturated with areas of red and brown drainage." When nursing assistants repositioned the resident during care, neither positioned the phalange on the boot nor provided any positioning to keep the leg in the correct position. Additionally, the top of the white soft splint showed "brownish stains, which Staff J and Staff K identified as dried bowel movement."
During wound care on August 7, 2024, staff removed the dressings to reveal "a dime-sized wound, reddened, top layer of skin missing" on top of the foot, and on the heel "an opened wound the size of a golf ball that had blackened areas, white areas, and areas of red flesh."
Review of treatment records revealed significant gaps in care. In June 2024, eight of 23 treatment opportunities for the heel wound were not completed, and six of 11 opportunities for the knee wound were missed. July records showed 10 of 36 heel treatments and 12 of 30 knee treatments were not performed.
The facility's contracted wound care provider was unable to see the resident until 41 days after the wounds developed due to scheduling conflicts with the resident's dialysis treatments. On July 30, 2024, the wound specialist assessed the injuries as stage 3 pressure injuries requiring surgical debridement to remove dead tissue.
When interviewed, nursing assistants acknowledged they had not received specific training on the positioning boot or proper leg positioning. The Interim Director of Nursing Services confirmed that staff had not been trained on the equipment and that no directives existed in the resident's care plan for proper positioning.
Pressure injuries represent a significant concern in long-term care settings because they can lead to serious complications including infection, sepsis, and prolonged hospitalization. Stage 3 wounds, which involve full-thickness skin loss exposing underlying fat tissue, require intensive treatment and can take months to heal. The presence of dead tissue necessitating surgical debridement indicates wound progression that proper prevention protocols should have addressed.
Dementia Resident Exits Facility Multiple Times
Inspectors documented repeated elopement incidents involving a resident with vascular dementia—a condition causing impaired reasoning, planning, judgment, and memory due to reduced blood flow to the brain. The resident's comprehensive assessment indicated they were cognitively impaired and unable to make sound decisions.
Despite documented behavioral concerns beginning in mid-July 2024—including "combative behavior," "behaviors distressing others," "wandering behavior," and "observed exit seeking"—the resident's initial elopement risk assessment rated them as low risk for elopement. The facility did not reassess the resident's elopement risk until after a second incident on August 6, 2024.
A family member reported that the resident "got out the window of their room" shortly after admission. Following this incident, the resident was provided with a wander guard alarm bracelet. However, surveyors observed on August 7, 2024, that when the resident opened an exit door at the end of a hallway, "which had a keypad alarm," the door "did not alarm when the resident walked out the doorway."
Testing of the facility's alarm system revealed significant gaps. When the Administrator provided a wander guard to the Maintenance Director to test the main front door, "the door did not alarm." The Maintenance Director explained that only certain doors were configured for the wander guard system, and that employees using keypad alarms to exit "do not reset the alarms."
Further inspection of the courtyard revealed that two gates leading to the parking lot had "unlocked latch locks." The Administrator acknowledged the gates could be locked but stated they remained unlocked due to fire egress requirements.
The facility's progress notes documented the resident's escalating behaviors, yet interdisciplinary meeting notes from July 12 through August 1, 2024, showed "no concerns regarding mood or behavior." The Administrator acknowledged that elopement incidents were not reported to the state agency as required.
Elopement poses serious safety risks for cognitively impaired individuals who may be unable to navigate safely, recognize dangers such as traffic, or find their way back to safety. In cases of dementia, residents may experience disorientation that intensifies during nighttime hours, making comprehensive monitoring and properly functioning alarm systems essential protective measures.
Diabetic Dialysis Patient Misses Critical Medications
A resident receiving dialysis treatments three times weekly for end-stage kidney disease experienced systematic gaps in medication administration, including insulin for diabetes management. Review of medication records from June through August 2024 revealed a pattern of missed doses coinciding with dialysis days.
In June 2024, 13 of 30 days showed morning medications were not administered. July records documented that core medications—including those for heart failure, blood pressure, mood disorders, and wound healing—were not given on 12 of 31 shifts. Blood-thinning medication ordered to prevent blood clots was missed on 10 of 31 days.
The resident's insulin management showed similar deficiencies. In June, long-acting insulin was not administered on 13 of 30 shifts, and short-acting insulin with blood sugar monitoring was missed on 25 of 60 shifts. July records showed 23 of 52 shifts without short-acting insulin administration or blood sugar monitoring.
A nurse explained that the resident left the facility at 7:00 AM for dialysis and did not return until approximately 2:00-2:30 PM. The nurse stated they "did not give Resident 23 their medications, insulin, or monitor their blood sugar levels prior to them leaving for dialysis because Resident 23 left the facility too early."
Critically, staff did not communicate to the dialysis facility that the resident had not received medications, insulin, or blood sugar monitoring before leaving. The Resident Care Manager stated they were unaware of the systematic medication gaps and believed "the physician was most likely unaware."
For individuals with diabetes and end-stage kidney disease, consistent insulin administration and blood sugar monitoring are essential. Dialysis itself affects blood sugar levels, and skipping insulin doses can result in dangerous glucose fluctuations. The combination of missed heart medications, blood thinners, and diabetes management drugs creates compounding risks for cardiovascular events and metabolic complications.
Additional Issues Identified
The inspection identified numerous other deficiencies across multiple care areas:
Mental Health Screening Failures: Four of five residents reviewed had inaccurate Preadmission Screening and Resident Review (PASARR) documentation. Residents with diagnosed anxiety and depression receiving psychotropic medications did not have these conditions properly identified, potentially preventing them from receiving appropriate mental health services.
Care Plan Deficiencies: Multiple residents lacked baseline care plans within the required 48 hours of admission. One resident stated, "I wish they would have so I would have known what the plan was for getting better and being able to go home." Another resident with metastatic cancer had no care plan addressing their cancer diagnoses or ongoing treatment needs.
Trauma-Informed Care Gaps: A resident with documented PTSD experienced a frightening incident when a male resident with dementia entered their room at night and stared at them while they were in bed. The resident reported the event triggered their PTSD from past trauma, yet no staff followed up regarding their diagnosis or implemented interventions to prevent recurrence.
Skin Care Failures: A resident with an ongoing rash received a 14-day order for medicated powder that expired in early July, yet the rash persisted through August with no new treatment orders obtained despite weekly skin assessments.
Respiratory Equipment Issues: Residents using nebulizers and oxygen had equipment stored improperly without protective covering. One resident was using oxygen without any physician order specifying dosage or monitoring requirements.
Infection Control Violations: Staff were observed providing incontinence care without changing gloves between dirty and clean tasks, and performing hand hygiene for only four seconds rather than the required minimum. The facility also lacked established testing protocols for its water management program to prevent Legionella growth.
Food Safety Concerns: Syrup containers in dry storage lacked expiration dates, and a nutritional refrigerator contained undated foods with a "dark brown substance" on the bottom and old food particles stuck to the walls.
Environmental Hazards: A laundry room washing machine had been leaking for months, causing damage to laminate flooring that oozed "grayish sludge" when walked upon.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Richland Rehabilitation Center from 2024-08-12 including all violations, facility responses, and corrective action plans.
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