South Boston Health & Rehab Center

Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide adequate supervision and ensure the environment was free of accident hazards to prevent residents from exiting the facility without staff knowledge and resulted resulting in one resident (Resident #3- R3) having eloped the facility for an undetermined amount of time. The deficient practice had the potential to affect residents identified at risk for elopement residing on two of the three occupied units, which resulted in the identification of Immediate Jeopardy (IJ) and substandard quality of care. Immediate jeopardy began on 1/17/25 and when removed on 12/4/25, the scope and severity was lowered to a level two, isolated (D).

Inspectors wroteBased on resident interviews and staff interviews, the facility staff failed to ensure residents received mail timely and on weekends for three of three nursing units.

Inspectors wroteBased on observations, staff interviews and facility documentation, the facility staff failed to label and store medications properly on three of five medication carts inspected.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen.

Inspectors wroteBased on staff interview and facility documentation review, the facility staff failed to implement an infection control program that included infection surveillance, affecting residents on 3 of 3 nursing units.

Inspectors wroteBased on staff interview, clinical record reviews, and facility documentation review, the facility staff failed to implement an antibiotic stewardship program which affected residents on three of three units and failed to follow antibiotic stewardship for two residents (Resident #16-R16 and Resident #61-R61), who were actively receiving antibiotics.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 vaccines to three residents (Resident #147-R147, Resident #145-R145, and Resident #146-R146) in a survey sample of five residents selected for immunization review.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were free from chemical restraints and unnecessary psychotropic medications for one resident (Resident #63-R63) in a survey sample of 23 residents.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to include initial care needs for a PICC (peripherally inserted central catheter) and a suprapubic catheter in the baseline care plan for one of twenty-three residents in the survey sample (Resident #145).

Inspectors wrote2. Resident #144 was not administered medications as ordered by the physician. Resident #144 (R144) was admitted with diagnoses that included atrial fibrillation, COPD (chronic obstructive pulmonary disease), lung cancer, congestive heart failure, anxiety, depression, hypertension, respiratory failure and atherosclerotic heart disease. The minimum data set (MDS) dated [DATE] assessed R144 as cognitively intact. On 5/20/25 at 10:22 a.m., R144 was interviewed about quality of care since her admission to the facility. R144 stated she was admitted on [DATE] around 6:00 p.m. and that she did not receive her heart and sleep medications on the evening of her admission. R144 stated around 8:30 p.m., she asked the certified nurses' aide (CNA #3) caring for her about getting her medications. R144 stated the CNA told her that the nurse would be in shortly to give medications. [...]

Inspectors wrote2. The facility did not provide a rationale for a gradual dose reduction of Seroquel for Resident #59 (R59). The Findings Include: Diagnoses for R59 included; Dementia, major depression, and mood disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/8/25. R59 was assessed with a cognitive score of 8 out of 15, indicating moderately impaired. Review of R59's current medications indicated R59 was ordered 12.5 MG of Seroquel (antipsychotic) every night for mood disorder. The order was dated 11/6/25. Review of pharmacy recommendations indicated, through consultation reports, a gradual dose reduction (GDR) of seroquel on 2/18/25 and 5/16/25 had been recommended. On the Consultation Report, the physician had placed a check mark indicating not to do a GDR. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain a complete clinical record for one resident (Resident #63-R63) in a survey sample of 23 residents.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to have evidence of residents being provided education and offered flu and pneumococcal immunizations for two residents (Resident #145-R145 and Resident #146-R146) in a survey sample of five residents reviewed for immunizations.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to protect a resident's right to be free from sexual abuse for one resident (Resident #8 - R8) in a survey sample of 10 residents, which resulted in harm for R8.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to have credible evidence of a complete and thorough investigation being conducted following an incident of sexual assault involving two residents (Resident #8- R8 and resident #9-R9) in a survey sample of 10 residents.

Inspectors wroteBased on observations, staff interview, and facility documentation review, the facility failed to provide functional furniture appropriate for resident use in 2 rooms (rooms 208 & 323), on 2 of 4 units.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to notify the physician for a need to alter treatment for one of 36 residents in the survey sample, Resident #313. The facility failed to notify the physician that Resident #313 had not received physician ordered IV (intravenous) antibiotics for 5 days, and failed to notify the physician that the IV antibiotic medication was not available for administration, which resulted in the identification of Immediate Jeopardy (Level 4-Isolated) on 01/25/2022 at 4:25 PM.

Inspectors wrote4. Resident #88 was admitted to the facility on [DATE] with diagnoses that included diabetes (type 2), chronic kidney disease, diabetic neuropathy, peripheral vascular disease, hyperlipidemia, major depressive disorder, macular degeneration, vascular dementia, left above knee amputation and urinary tract infection. The minimum data set (MDS) dated [DATE] assessed Resident #88 with moderately impaired cognitive skills. A medication pass observation was conducted on 1/26/22 at 7:41 a.m. with licensed practical nurse (LPN) #11 administering medications to Resident #88. Among the medications administered was metformin 500 mg (milligrams). Resident #88 took the medicines including the metformin orally with water but no food. LPN #11 did not prompt or offer food with the administration of the metformin. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility staff failed to ensure a safe, clean, homelike environment on two of four units. Rooms on unit 1 and unit 3 had damaged call bell panel boxes that were loose and/or pulled from the wall in addition to, a dirty/damaged heat unit panel and scraped wall in room [ROOM NUMBER].

Inspectors wroteBased on review of employee personnel files, staff interview, and review of facility policy, the facility failed to implement their Virginia Resident Abuse Policy for the screening of new employees, for 11 of 25 personnel files reviewed. Eleven of 25 employee personnel files did not include a Sworn Statement.

Inspectors wroteBased on resident interview, group interview, facility document review and staff interview, the facility staff failed to ensure call bell response was timely on three of four nursing units. Interviews with residents from unit 1, unit 2 and unit 3 revealed call bell response times greater than 20 minutes.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide a timely response to pharmacy recommendations for 4 of 36 residents in the survey sample, Residents #87, #110, #14, and #149. The facility staff failed to act upon pharmacy recommendations regarding the need for the shingles vaccine for Residents #87, #110, #14; for the use of the medication Singular with diagnosed psychiatric conditions that included major depression and anxiety for Resident #14; and a recommendation for a dose reduction and/or discontinuation of medications related to falls for Resident #149.

Inspectors wroteBased on clinical record review, staff interview and facility document review, the facility staff failed to ensure a pharmacy recommendation for a gradual dose reduction (GDR) was completed for one of 36 in the survey sample, Resident #110. Resident #110's physician signed a GDR pharmacy recommendation for the antidepressant, Escitalopram (Lexapro) to be decreased from 15 mg (milligrams) daily to 10 milligrams daily. The order was not completed for over 4 months.

Inspectors wroteBased on observation, staff interview, resident interview, facility document review and clinical record review, the facility staff failed to follow infection control practices on one of four units, and failed to store respiratory equipment in a sanitary manner for one of 36 residents in the survey sample, Resident #121. Facility staff failed to don required personal protective equipment (PPE) and perform required hand hygiene during meal tray service on the yellow (warm) quarantine section of unit 1. On multiple days of the survey, Resident #121's nebulizer mask was observed on the floor with no protective cover.

Inspectors wroteBased on staff interview, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure DNR (Do Not Resuscitate) status was followe for one of 36 residents in the survey sample, Resident # 213. Resident # 213 had an advance directive for a DNR and facility staff initiated emergency services for CPR (Cardiopulmonary Resuscitation).

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to respond to a resident grievance regarding lost and/or missing clothing for one of 36 residents in the survey sample, Resident #149.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 36 residents was free from verbal/mental abuse, Resident #121. A certified nurses' aide (CNA) made derogatory remarks/comments to and about Resident #121. CNA #1 berated Resident #121 along with use of a hand gesture regarding the resident's slow consumption of breakfast in the presence of a state surveyor and two roommates.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure physician's orders for care of a central venous access device was in place upon admission, for one of 36 residents, Resident #313.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a comprehensive plan of care for two of 36 residents in the survey sample, Resident #61 and #18. Resident #61 had no plan of care regarding a colostomy. Resident #18 had no plan of care developed regarding use of insulin.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 36 residents in the survey sample, Resident #155 and #94. Resident #155's plan of care was not revised to reflect discontinued use of bed/chair alarms. Resident #94's plan of care was not updated to reflect a change in resuscitation status.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure physician ordered, IV (intravenous) antibiotic medication was available for administration for one of 36 residents in the survey sample, Resident #313.

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to provide dental services for one of 36 residents in the survey sample, Resident #57. Resident #57 had no follow-up dental services provided regarding acquisition of dentures.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen of the facility.

Inspectors wroteBased on observations, staff interviews, facility document review, and review of manufacturer's instructions, the facility staff failed to properly calibrate glucometers on two of four nursing units, Butterfly Path and Serenity.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure the accuracy and privacy of the resident's clinical record for one of 37 residents in the survey sample, Resident # 76. A nursing Progress Note in Resident # 76's clinical record included the names of three other residents.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure professional standards of practice by a hospice provider for one of 36 residents in the survey sample, Resident #122. Records of weekly hospice visits for Resident #122 were not provided to the facility as required in the hospice services agreement.

Inspectors wroteBased on staff interview, facility document review, and facility training record review, the facility staff failed to ensure 2 of 182 employees were up-to-date for abuse, neglect, and exploitation training.

Inspectors wroteBased on staff interview and training hours review, the facility staff failed to ensure one of 44 CNA's (certified nursing assistant) had the required 12 training hours per year.

Inspectors wroteBased on dining observation, resident interview, and staff interview, the facility staff failed to ensure a dignified dining experience in one of three dining room in the facility. Approximately twelve residents residing on the Season's unit (a memory care unit), were seated together at two tables and served at different times.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, the facility staff failed to apply physician ordered protective sleeves for one of 37 residents in the survey sample (Resident #13); and failed to follow professional standards of practice for medication administration for one of 37 residents in the survey sample (Resident #345).

Inspectors wroteBased on observation, resident interview and staff interview, the facility staff failed to ensure a safe, homelike environment on two of five nursing units. A resident room on unit 2 had constantly running water in the sink, a malfunctioning bathroom door, holes in the bathroom wall and a broken air freshener holder. A resident room on unit 1 had a broken/missing toilet paper holder and holes in the bathroom wall.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to develop a baseline care plan for tube feeding for one of 37 Residents, Resident #396. The findings Include: Resident #396 was admitted to the facility on [DATE]. Diagnoses for Resident #396 included; Alzheimer's disease, dementia, diabetes, and placement of a gastrostomy tube (feeding tube). The most current MDS (minimum data set) was not completed at the time of the survey due to Resident #396 being a new admission. On 10/9/19 Resident #396's medical record was reviewed and indicated that Resident #396 was newly admitted with a feeding tube. Review of Resident #396's baseline care plan documented a check mark beside feeding tube, but did not indicate any goals or interventions for the care of Resident #396's feeding tube. On 10/09/19 at 9:26 AM, MDS coordinator (registered nurse, RN #1) was interviewed. [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to follow physician's orders for treatment and care of skin integrity for two of 37 resident's. Resident #86 did not have heels floated or elbow protector while in bed per physician o5rders, and Resident #13 did not have a properly functioning air matress in place. The Findings Include: 1. Resident #86 was admitted to the facility on [DATE]. Diagnoses for Resident #86 included: Hemiplegia, sepsis, bed confinement status, and cerebrovascular accident. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 8/13/19. Resident #86 was assessed as moderately cognitively intact. On 10/9/19 Resident #86's medical record was reviewed. [...]

Inspectors wroteBased on observation, staff interview, family interview, resident interview and clinical record review, the facility staff failed to ensure podiatry services for one of 37 residents, Resident #110.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to implement fall interventions to prevent accidents for 1 of 37 in the survey sample. Resident #15, who was identified as having a history of falls was observed without a fall mat beside the bed.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure physician's orders for the care and maintenance of a PICC (Peripherally inserted central catheter) line for one of 37 residents, Resident #346.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of 37 residents in the survey sample. Resident #13's clinical record inaccurately documented a physician's order for restorative dining services.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure appropriate infection control practices to identify and control infections for two of 37 residents, Resident #195 and Resident #346.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to perform a bed safety inspection prior to installation of a specialty mattress for one of 37 residents in the survey sample. A specialty air mattress was installed and in use by Resident #13 without a prior inspection for bed safety to minimize entrapment risks.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for 1 of 37 in the survey sample. Resident #15's care plan was not revised to reflect the discontinued nutritional shake.