Life Care Center of South Hill

Inspectors wroteBased on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 2 sampled residents (Resident 142) when reviewed for grievances. This failure placed the residents at risk for lack of comfort and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safety interventions to ensure safety from potential further abuse for 1 of 3 sampled residents (Resident 143) when reviewed for abuse. This failure placed the resident at risk for physical harm, mental anguish, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to develop care plans for 1 of 19 sampled residents (Resident 126) when reviewed for comprehensive care plans. Failure to care plan Resident 126's bowel functions and half a side rail equipment placed the Residents at risk of avoidable injuries, loss of functions and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide ordered bowel medications for constipation per provider's orders for 2 of 5 sampled residents (Residents 136 and 124) when reviewed for quality of care. This failure placed the residents at risk for decreased comfort and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and implement residents' fluid restrictions for 1 of 2 sampled residents (Resident 132) when reviewed for nutrition. This failure placed residents at risk of fluid overload, discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Resident 121) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs and potential negative outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper storage of medications in 1 of 6 halls (700 hall) when reviewed for medication storage. This failure placed residents at risk for medication errors, ineffective treatment, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed received care and treatment in accordance with professional standards of practice regarding placement of an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). This failure placed residents at risk of unmet care needs, pain, and medical complications

Inspectors wroteBased on interview and record review, the facility failed to provide an ordered medication, significant to the health of the resident, for 1 of 6 sampled residents (Resident 27) reviewed for medication administration. Resident 27 experienced harm when they developed stroke like symptoms and was emergently transferred to the hospital for a change in condition. The facility has corrected the above deficiency prior to the standard survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to include all required services in the plan of care for 3 of 20 sampled residents (Residents 40, 42, and 226) when reviewed for comprehensive care plan. This failure placed residents at risk of not receiving required services, staff being unaware of how to assist residents, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor and document bowel movements and implement the bowel program as needed for 3 of 4 sampled residents (Residents 177, 176 and 40) reviewed for care and services. These failures placed the residents at risk for worsening condition, discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately monitor resident fluid intake and/or ensure dietary and supplement orders were obtained/transcribed according to standard of practice for 2 of 2 sampled residents (Residents 40 and 42) reviewed for nutrition. This failure placed residents at risk of fluid overload, swelling, discomfort, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement non-pharmacological interventions (NPI, methods to reduce pain without medication) prior to providing pain medications for 5 of 5 sampled residents (Residents 6, 24, 32, 41 and 226) reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary pain medications and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to timely initiate monitoring of adverse side effects and target behaviors for 3 of 6 sampled residents (Residents 24, 276 and 226) when reviewed for unnecessary psychotropic (affecting the mind) medications. These failures placed the residents at risk for unidentified mental health needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an infection control program that included the application of enhanced barrier precautions (EBP) for 2 of 3 sampled residents (Residents 5 and 226) when reviewed for EBP. Also, the facility failed to track all infectious organisms for 2 of 3 months (August and September 2024) when reviewed for infection control. These failures placed residents at risk of communicable diseases, avoidable side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 1 of 2 sampled residents (Resident 26) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to provide information on formulating an advanced directive for 1 of 3 sampled residents (Resident 36) when reviewed for advanced directives. This failure placed residents at risk of not having an established decision maker, lacking input into care, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the minimum data set assessment (MDS), an assessment tool, accurately reflected resident status for 1 of 20 sampled residents (Resident 226) reviewed for accuracy of assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 1 of 2 sampled residents (Resident 72) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, dehydration, and other adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Residents 226) reviewed for respiratory care. Failure to transcribe/obtain and follow physician orders for oxygen (O2) therapy, care plan, ensure O2 tubing was regularly changed and maintained, placed the resident at risk for unmet needs and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 4 of 4 days of the survey period. This failed practice prevented residents, family members and visitors from knowing the facility's actual number of available nursing staff.

Inspectors wroteBased on interview and record review, the facility failed to properly notify the Office of State Long-Term Care Ombudsman (SLTCO, an advocacy group for residents in a nursing home) of discharges for 2 of 4 sampled residents (Residents 177 and 42) reviewed for hospitalization. These failures placed residents at risk for being inappropriately discharged , lack of access to an advocate who could inform them of their options and rights, and to ensure that the SLTCO was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 4 of 4 sample residents (Residents 177, 27, 42, and 47) reviewed for hospitalization. This failure placed residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital. Resident 177 Review of Resident 177's entry minimum data set (MDS), an assessment tool, dated 09/22/2024, showed the resident readmitted on [DATE] with diagnoses to include heart and kidney disease, diabetes, depression and anxiety. The MDS showed Resident 177 was able to make needs known. During an interview on 10/28/2024 at 10:19 AM, Resident 177 stated they had been transferred to a local medical center for treatment of shingles (a viral infection that causes a painful rash) several weeks ago; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prohibition policy for 2 of 6 residents (Residents 10 & 11) reviewed for abuse. The failure to properly identify a resident grievance as an alleged violation and report the alleged violation to the State Agency (SA) placed residents at risk for further exposure to potential abuse/neglect, unmet care needs, and diminished quality of life/quality of care.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prohibition policies and procedures for 2 of 6 residents (Residents 10 & 11) reviewed for abuse. The failure to conduct a thorough investigation of an alleged violation and maintain documentation to show an alleged violation was thoroughly investigated that included immediate interventions implemented to prevent further potential abuse/neglect during (and after) the investigation placed residents at risk for further exposure to potential abuse/neglect, unmet care needs, and diminished quality of life/quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 residents (Resident 3) reviewed for medication administration. The failure to follow, obtain, and/or clarify physician orders, only sign for medications administered placed, and accurately document medication timing requests placed residents at risk for medication errors, delay in treatment, and adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement the personalized discharge plan for a smooth transition to the community for 1 of 3 residents (Resident 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure temperature control and labeling of food items to provide safe, sanitary food storage in 2 of 2 resident food refrigerators (Cascade and Olympic refrigerators) when reviewed for Kitchen. This failure placed residents at risk of consuming expired food items, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide dialysis care and services to meet the needs of one resident (Resident 14) of one sampled resident reviewed for dialysis. The facility failed to provide consistent monitoring of the dialysis documentation of communication, to the dialysis unit, to inform them of pertinent clinical information. This failure placed the resident at risk for unmet care needs.