South Hill Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at South Hill Rehabilitation and Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 10, 2023

  Based on observation, interview, and record review, the facility failed to provide the identified transfer assistance required to prevent injury for one of five sample residents (1), reviewed for accidents and supervision. This failure resulted in actual harm to Resident 1, who sustained a fracture and pain during a transfer without utilization of a two-person assist and appropriate equipment, as required. Findings included . Per the 11/24/2022 quarterly assessment, Resident 1 required extensive assistance of one staff for transfers, was not steady, and had no falls since admission to the facility. […]

• Actual harm, isolatedF740Apr 15, 2022

  Based on interview and record review, the facility failed to provide the necessary behavioral healthcare to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 sample residents (1), reviewed for care and services. Specifically, Resident 1 was checked for toileting needs in an undignified manner, was upset and afraid the identified person (Staff A) was going to return, and did not receive any follow-up by the facility related to the incident, or the resident's expression of distress. This failure caused the resident actual psychosocial harm. Findings included: A review of the record showed Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF760Jan 7, 2022

  Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (1), reviewed for medication administration, was free from significant medication errors. Failure to transcribe the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Per the admission record, Resident 1 admitted to the facility on [DATE] following a hospital stay, where they received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record also showed the resident had diabetes mellitus, (a condition caused by the pancreas being unable to produce enough insulin), and used a CGM (a system which used a tiny sensor wire inserted just under the skin to monitor blood sugar levels in the body), and an insulin pump to provide insulin, to manage the resident's… […]

• Actual harm, isolatedF689Apr 2, 2021

  Based on interview and record review, the facility failed to provide adequate supervision to prevent a fall for one of three sample residents (#1), reviewed for falls. This failure led to actual harm for Resident #1, who fell from a raised bed while unsupervised, and sustained a fracture. Findings included . According to the 02/11/2021 assessment, Resident #1 was admitted with [DIAGNOSES REDACTED]. The resident had memory impairments, difficulty making her needs known, and required extensive assistance with activities of daily living. Review of the resident's 01/29/2021 updated care plan showed the resident was at risk for falls due to weakness. […]

• No harm, potential for more than minimal, widespreadF801Feb 22, 2024

  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. […]