South Hill Rehabilitation and Care Center

Based on interview and observation, the facility failed to ensure medications carts were locked/secured in the absence of a nurse, expired medications were discarded timely, and injectable medications were dated/timed when opened. These failures placed the residents at risk of unauthorized access to medications and their potential adverse effects, theft or diversion of medications, and decreased potency and safety of the medications. Findings included . <Unsecured Medication Cart> An observation on the second floor on 06/09/2025 at 9:06 AM showed an unlocked and unattended medication cart stationed at the beginning of Unit B - Transitional Care Unit. In this continuous observation, Staff C, Licensed Practical Nurse (LPN) approached the medication cart. At 9:30 AM, the medication cart was again observed unlocked and unattended, and Staff C was coming from Unit B, Long Term Care Unit. Staff C acknowledged the medication cart was opened and that it should have been locked, and stated it should be secured, When we are away. <Expired Medications> On 06/18/2025 at 01:45 PM, during an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to identify a designated interdisciplinary team member, to act as a liaison for coordinating care and communication with the hospice provider, for 1 of 1 sampled residents (Resident 37), reviewed for hospice services. This failure placed the resident at risk for unmet care needs. Findings included The 05/05/2025 significant change assessment documented Resident 37 was able to make decisions regarding their care, had diagnoses which included malnutrition, asthma, and respiratory failure. In addition, the assessment documented the resident received hospice services. Review of Resident 37's record showed a referral was made on 04/16/2025 for hospice services, and serv ices were started on 05/01/2025. Review of the facility's 05/01/2025 hospice agreement documented the services and responsibilities for care that would be provided by both the facility and the hospice provider; however, the policy did not include and/or document who the designated facility liaison to hospice was that was responsible for collaborating in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) reviewed for quality of care, received timely notification to the medical provider of a change in condition. This failure placed the resident at risk of delayed access to care, inability to participate in care planning, and diminished quality of life. Findings included . Review of the skilled nursing facility transfer orders dated [DATE] for Resident 2 showed they were discharged from the hospital in stable condition following an episode of respiratory failure. The oxygen therapy orders showed the resident was to receive oxygen at 2-3 liters per min (LPM; a unit of measure) via a nasal cannula (thin flexible tube with prongs that go inside the nostrils), and the resident had adamantly declined non-invasive positive pressure ventilation (respiratory support where air and oxygen is given through a mask under positive pressure). Per Resident 2's Portable Orders for Life-Sustaining Treatment (POLST) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to investigate resident-reported concerns (grievances) and to provide timely follow-up for 1 of 5 sampled residents (Resident 2), reviewed for grievances. This failure placed the resident at risk of having unresolved grievances and a diminished quality of life. Findings included . Review of the policy titled, Safeguarding Residents' Belongings, revised December 2023, showed the facility would promptly respond to and investigate complaints of missing property, and the Administrator or their designee would notify the resident of the results of the investigation and corrective action taken within 10 working days. In an interview on 03/29/2024 at 1:18 PM, Resident 2 stated during their admission to the facility they had reported to multiple unidentified nursing assistants and one unidentified charge nurse a concern about missing property (a notebook) and missing money (stored inside the notebook). The resident stated they were told by the charge nurse that facility administration was aware of the concern and were investigating.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an allegation of potential misappropriation was reported to the State Agency as required, for one of five sampled residents (Resident 2) reviewed for abuse. This failure placed residents at risk for possible abuse. Findings included . In an interview on 03/29/2024 at 1:18 PM, Resident 2 stated during their admission to the facility they had reported to multiple unidentified nursing assistants and one unidentified charge nurse a complainant about missing property (a notebook) and missing money (stored inside the notebook). The resident stated they were told by the charge nurse that facility administration was aware of the concern and were investigating. Review of the January to April 2024 incident logs showed no entries for Resident 2. In an interview on 04/09/2024, Staff C, Charge Nurse, confirmed Resident 2 had mentioned missing property and money to them, and they had notified the resident that facility administration was investigating the complaint. Staff C stated they were not involved in the investigation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to care plan and implement an identified intervention for 1 of 5 sampled residents (Resident 3) reviewed for care planning. This failure placed the resident at risk of unmet needs and diminished quality of life. Findings included . Review of a facility investigation dated 03/15/2024 showed Resident 3 made a statement about trauma from their past that was triggered by cares provided by a (male) nurse the previous night. Per the investigation, the resident's care plan was updated to include female-only care for personal care. Review of Resident 3's care plan, effective 03/11/2024 to 04/20/2024, showed no interventions for female-only care for personal care. The [NAME] (summarized version of the care plan) for the same timeframe also showed no interventions for female-only personal care. In an interview on 04/09/2024 at 12:39 PM a representative for Resident 3 stated they were told Resident 3 would have female-only staff provide personal care after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to thoroughly investigate the cause(s) of falls and assess the need for additional effective interventions for 1 of 3 sampled residents (Resident 1), reviewed for accident hazards. This failed practice placed the resident at risk for additional falls, injury secondary to falls, and diminished quality of life. Findings included . Review of the 03/06/2024 significant change assessment showed Resident 1 was severely cognitively impaired and had a history of falls. Additionally, the resident required moderate staff assistance for transfers, toileting, and walking, and supervision in their wheelchair. Review of Resident 1's care plan for falls, initiated 04/27/2023, showed staff were to offer toileting assistance every two hours and assess for unmet needs, ensure the resident's floor was clean and free of clutter, encourage appropriate footwear, ensure the bed was at an appropriate height to allow for safe transfers, and provide a room in a highly trafficked area to facilitate frequent observation. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate licensing necessary to carry out the functions of the nutritional services for 91 residents. Failure to ensure the Registered Dietician (RD) had a license to practice in Washington State placed residents at risk for unmet nutritional needs and possible unintended weight loss or gain. Findings included . On 02/21/2024, a review of the staff credentials showed Staff K, Registered Dietician (RD), had successfully completed requirements for dietetic registration through the Academy of Nutrition and Dietetics Commission on Dietetic Registration, with a certificate valid through 08/31/2024. A copy of Staff K's license to practice in Washington State was also requested and none was provided. A search of the Washington State Department of Health Provider Credential database found no record to show that Staff K had the required Dietician Certification (license) to practice as a dietician in Washington State. In an interview on 02/22/2024 at 11:08 AM, Staff K was asked if they were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure food was prepared in accordance with professional standards for food service safety. Specifically, the facility failed to ensure the kitchen staff with facial hair were wearing beard restraints (nets) to prevent hair from contacting exposed food and clean equipment. Unsafe food handling practices placed the residents at risk of unsanitary food and possible foodborne illness. Findings included . A document from the United States Food & Drug Administration Food Code website titled Food and Drug Administration Food Code 2022, Chapter 2. Management and Personnel Section 2-402 Hair Restraints updated on January 18, 2023, showed that food employees shall wear coverings over their hair and beards to prevent hair from contacting exposed food and clean equipment. On 02/13/2024 at 8:49 AM, during a tour of the kitchen, Staff J, Cook, was observed chopping fresh fruit. Staff J had a full beard of short hair, without a beard net in place. On 02/22/2024 at 10:24 AM, during a second visit to the kitchen, Staff L,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide a dignified dining service for 1 of 1 sampled resident (341). Specifically, Resident 341 was referred to as a feeder on their printed meal ticket. This failure placed the resident at risk for psychosocial harm and decreased quality of life. Findings included . On 02/21/2024 at 12:02 PM, Resident 341 was served lunch in the 2nd floor dining room. A meal ticket listed the Resident name, diet, and assistance level as 1:1 Feeder. The meal ticket was placed face-up on the table in front of the resident, and visible to residents, staff and visitors. On 02/21/2024 between 12:15 PM and 12:37 PM, Resident 341 ate their meal without staff assistance, and at 12:57 PM, had finished eating and left the dining room independently in their wheelchair. During an interview on 02/22/2024 at 10:31 AM, Staff Q, Nursing Assistant, stated they knew what level of assistance a resident needed at meals by reading the meal ticket. Staff Q stated if they needed to communicate the level of assistance a resident needed with eating or drinking,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the facility failed to thoroughly investigate an allegation of abuse involving a bruise of unknown origin for 1 of 3 sampled residents (68) reviewed for skin conditions. This failure placed residents at risk for potential mistreatment and decreased quality of life. Findings included . According to the 02/12/2024 quarterly assessment, Resident 68 had diagnoses including schizoaffective disorder and had a history of falling. Resident 68 was severely cognitively impaired and required substantial staff assistance for their activities of daily living (ADLs). A review of the Accidents and Incidents log documented that on 02/06/2024, Resident 68 had a bruise of unknown origin on their right leg, the investigation was still pending, and this was reported to the State Reporting Agency. The undated Incident Investigation documented Resident 68 had bruising to the right interior upper leg found by Staff E, Nursing Assistant (NAC), during cares. Staff E notified the licensed nurse. Staff E gave a statement that they noticed a large bruise on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dependent residents services to maintain their personal hygiene for 1 of 2 sampled residents, (341), reviewed for activities of daily living (ADLs) for dependent residents. Specifically, the facility failed to provided nail care. This failure had the potential to place the resdient at risk for unmet care needs and diminished quality of life. Findings included . A review of the record showed Resident 341 had a diagnosis of arthritis (inflammation of the joints that caused pain and stiffness) and needed assistance with personal care. A 02/07/2024 quarterly assessment showed the resident had frequent pain that limited day-to-day activities and required extensive assistance with most ADLs, including hygiene and bathing. The 02/07/2024 ADL care plan instructed nursing staff to perform nail care twice a week on the residents shower days. A review of Resident 341's record from admission on [DATE] to 02/22/2024 showed no documentation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure blood pressure medications were consistently monitored for 2 of 5 sample resident (9, 53) reviewed for unnecessary medications. This failure placed the residents at risk for potential adverse side effects and medical conditions. Findings included . <Resident 53> Per the quarterly 02/12/2024 assessment, Resident 53 had diagnoses which included high blood pressure. Review of the Active Order Report showed the physician prescribed a blood pressure medication (Cardizem) on 07/20/2023 to be given every 12 hours. The order instructed nursing staff to hold the medication if the heart rate was less than 55 beats per minute or the systolic blood pressure was under 105. Review of the January and February 2024 MARs showed on 01/06/2024, 01/10/2024, 01/11/2024, 01/20/2024, 01/21/2024, 01/24/2024, 02/02/2024, 02/03/2024, 02/07/2024, and 02/08/2024, the PM dose of Cardizem was administered, but the blood pressure values were documented as zero's, and no actual blood pressure values were documented to show the blood pressure was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that 1 of 5 residents (32), reviewed for unnecessary medications, was free of significant medication errors. Specifically, Resident 32 had numerous medications that were not given as ordered, when they were at dialysis three times a week. This failed practice put the resident at increased risk of medical complications due to missed doses of important medications. Findings included . An agreement between the facility and the resident's dialysis center, dated 04/13/2021, showed that the facility was responsible for providing the dialysis center information about the resident's medications. According to a comprehensive assessment dated [DATE], Resident 32 was cognitively intact and made their needs known. The assessment further showed that Resident 32 had diagnoses which included end-stage renal disease (ESRD) that required dialysis three times a week (a treatment to filter wastes and water from the blood when the kidneys no longer work). A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food preferences were honored for 2 of 9 residents (Residents 9 and 48) reviewed for food. Specifically, the facility failed to thoroughly assess Resident 9's nutritional preferences for a Kosher diet, foods that are processed and prepared according to Jewish religion, and failed to ensure Resident 48 was provided foods they selected on their menus that they felt would assist them to lose weight. These failures placed the residents at risk for decreased quality of life. Findings included . <Resident 9> Per the 01/15/2024 quarterly assessment, Resident 9 was admitted to the facility on [DATE], was able to make decisions regarding their care, and was independent for eating. During the lunch observation on 02/13/2024 at 12:24 PM, Staff AA, Nursing Assistant requested a serving of the beef stew from Staff Z, dietary aide, for Resident 9. When Staff Z stated the resident doesn't normally eat meat, Staff AA stated it was all right, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure assistive eating equipment/utensil devices were provided for 2 of 9 sampled residents (14, 20) observed during dining. This failure placed residents at risk of decreased oral intake, weight loss, and nutritional complications. Findings included . Resident 14 Per the 01/13/2024 quarterly assessment, Resident 14 had diagnoses which included Parkinson's disease, a nervous system disorder that caused tremors, muscle rigidity, decreased mobility and slow voluntary movements. In addition, the assessment showed the resident was able to eat independently with only set-up assistance from staff. Review of the 01/03/2024 nutritional care plan instructed staff to provide assistance with eating as needed. In addition, the staff were informed the resident was to have a lipped plate, a plate that has a high wall with an inner lip that kept food from sliding off the plate and was used to push food onto the eating utensil, at meals. On 02/13/2024 at 12:21 PM, Resident 14 was observed eating lunch. The resident's lunch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure appropriate hand hygiene and glove changes were performed during wound care for 1 of 1 sampled residents (69) observed during a dressing change. This failure placed the resident at risk for infection and delayed wound healing. Findings included . The CDC recommended healthcare personnel should use alcohol-based hand rub or wash with soap and water .immediately before touching a patient, after touching a patient or the patient's immediate environment and immediately after glove removal. When washing hands with soap and water .rub hands together for at least 15 seconds. When using handrubs rub hands together covering all surfaces until dry. According to the 02/05/2024 quarterly assessment Resident 69 had diagnoses of Stage 4 sacral pressure ulcer (an injury of the tailbone area caused by prolonged pressure on the skin which extends into the muscle, tendon, ligament, cartilage or even bone), Osteomyelitis (an infection of the bone), and Paraplegia (a type of paralysis that affects the ability to move the lower half of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure 4 of 5 sample residents (33, 57, 365, 366), reviewed for advance directives, were provided with written information regarding advance directives, and the right to formulate one, to ensure the residents' desired level of medical care was known in the case of an inability to direct care on their own. Findings included: RESIDENT 33 Review of Resident 33's facility's printed Record of Admission showed a facility admission date of [DATE] with medical diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease characterized by persistent repiratory symptoms like progressive breathlessness and cough), major depressive disorder, asthma, high blood pressure, diabetes, and coagulation disorder (a disruption in the body's ability to control blood clotting). Review of Resident 33's electronic medical record showed a Physician's Order for Life Sustaining Treatment (POLST) form regarding cardiopulmonary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety. Observations revealed the facility failed to ensure 31 slices of pie were covered on rolling carts to be delivered to residents. Findings included: During an observation of the second-floor dining on 01/10/2022 at 12:10 PM, pies were observed to be on separate saucers and were uncovered. The pies were then put onto the meal tray and loaded into the cart. Pies remained uncovered on the meal tray. During observation of first-floor dining on 01/10/2022 at 12:18 PM, pies were observed uncovered and on small individual paper plates. The pies were then put onto residents' meal trays and put into the rolling tray cart. The pies remained uncovered on the meal tray. During observation of the second-floor tray pass on 01/10/2022 at 12:25 PM, Staff C, Nursing Assistant, was observed serving a meal tray with the pie uncovered. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's admission Packet, the facility failed to ensure 1 of 3 sample residents reviewed for choices (14), had choices and preferences honored regarding bathing/showers. Findings included: Review of the electronic medical record revealed Resident 14 was admitted to the facility on [DATE] from a hospital with diagnoses including coronary artery disease, depression, and chronic obstructive pulmonary disease (COPD - a lung disease characterized by persistent repiratory symptoms like progressive breathlessness and cough). Review of Resident 14's 10/20/2021 care plan showed that the resident was to have showers on Wednesdays and Sundays, and bed baths as needed. Review of the admission Minimum Data Set - a document required to thoroughly evaluate residents, dated 10/26/2021 showed a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Under the daily preferences section of the document, it showed that it was very…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.