Rock Hill Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Rock Hill Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835May 1, 2025

  Based on interview, and record review, the facility Administration failed to ensure the facility's finances were maintained effectively for continuity of resident care and services. The Administration was aware the facility was behind on vendor payments and receiving notices for discontinuation of services. The Administration's failure to ensure the facility met their financial obligations to vendors resulted in the facility laboratory services provider discontinuing services to the facility resulted in four residents (Residents 10, 34, 95, and 7) not receiving timely laboratory services, and placed all 41 residents at risk of not receiving necessary care and services and constituted an Immediate Jeopardy (IJ). On 04/25/2025 at 5:19 PM, the facility was notified of an IJ in F835. […]

• Immediate jeopardy, patternF770May 1, 2025

  Based on interviews and record review, the facility failed to ensure timely laboratory services were provided for 5 of 5 residents (Residents 7, 10, 15, 34 and 95) reviewed for laboratory services. Resident 15 did not have a urinalysis sample collected for laboratory study per physician order, Resident 7 did not have a Hemoglobin A1C (lab measures blood sugars in the body over a period) test completed as ordered and Resident 95 did not have a metabolic panel and blood count completed timely. Resident 10 and 34's Depakote levels (critical lab test to determine therapeutic drug level in the body and prevent toxicity for seizure medications, reference range 50-100) were not completed timely as ordered and constituted an Immediate Jeopardy (IJ). […]

• Actual harm, isolatedF686May 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure a pressure offloading mattress was ordered and implemented timely to prevent pressure ulcer (PU)/pressure injury (PI) development for 1 of 2 residents (Resident 7) reviewed for facility acquired PU. Resident 7 experienced harm when they developed a preventable Stage 3 PU to their coccyx (tailbone), requiring wound vacuum treatment which impacted the resident's rehabilitation and discharge potential. This failure placed residents at risk for adverse outcomes and a decreased quality of life. Findings included . […]

• Actual harm, isolatedF600Mar 14, 2024

  Based on interview, and record review, the facility failed to ensure a resident was free from neglect for 1 of 1 resident (Resident 1) when the facility failed to provide Resident 1 with the routine physician ordered Circulation Motor Sensory (CMS - a medical exam/check of the resident's neurological and vascular health) to their left leg. Resident 1 experienced harm when they were found with a Stage 4 (a full thickness tissue loss with exposed bone, tendon, or muscle. Nonviable tissue, dead or devitalized tissue may be present on some parts of the wound bed. […]

• Actual harm, isolatedF686Mar 14, 2024

  Based on interview, and record review the facility failed to ensure nursing staff consistently provided the skin integrity and Circulation Motor Sensory (CMS - a medical exam/check of the resident's neurological and vascular health) assessment and monitoring as ordered, for 1 of 1 resident (Resident 1) reviewed for pressure ulcer/pressure injury (PU/PI). Resident 1 experienced harm when they developed an avoidable Stage 4 (a full thickness tissue loss of tissue with exposed bone, tendon, or muscle. There may be nonviable tissue, dead or devitalized tissue present on some parts of the wound bed) PU/PI under the resident's knee brace (also known as an immobilizer - a medical device that stabilizes your knee joint and holds it in place). […]