South Hill Rehabilitation and Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to provide regular bathing for 3 of 6 sampled residents (Resident 2, 3,and 4). This failure placed residents for potential risk of infection, skin irritation, unpleasant body order, low self-esteem, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure accepted standards of clinical practice were met for care of a peripherally inserted central catheter (PICC) line (a long thin tube inserted through a vein in the arm and passed through to the larger veins near the heart) for 1 of 1 sampled resident (Resident 1). This failure placed residents at risk for potential delay in the administration of necessary intravenous (IV), administered through a vein, medications, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the development of adequate baseline care plans within the required timeframe to ensure continuity of care for 4 of 7 sampled residents (Resident 183, 180, 52 and 17) recently admitted to the facility. This failure placed the residents at risk for unmet needs and possible complications.

Inspectors wrote<Second Floor Dining Room> Observations of the meal showed the following on 06/09/2025: At 12:01 PM, Staff D, Speech Therapist, touched the back of a female resident seated at a dining room (DR) table. Staff D completed HH then grabbed a pair of gloves and put them on. Staff D approached another female resident, touched their wheelchair (WC) with the gloved hand, walked to the serving area to get a bowl of soup, and brought it to the female resident. Staff D then touched another resident's WC with the same gloves on, went to get ketchup at the serving area. Staff D returned to the resident with the same gloved hands, opened the burger bun, poured the ketchup on the burger, and moved it closer to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure signage was placed to inform the staff of residents (Resident 7, 77, 180, 182, 183, and 191) who required Enhanced Barrier Precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, germs that are resistant to many antibiotics]). Additionally, the facility failed to ensure hand hygiene was implemented as required during medication administration. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consents which explained the potential risks and benefits associated with the use of psychotropic medications and/or vaccines were accurately completed, and obtained from the resident or their representative prior to their administration, for 2 of 5 sampled residents (Residents 14 and 3) reviewed for unnecessary medications. In addition, the facility failed to ensure Resident 3 had the cognitive ability to understand the risks prior to signing the informed consent. These failures placed the residents and/or their representatives at risk of not being fully informed of the potential risks and benefits of receiving the medication and/or vaccines.

Inspectors wroteBased on interview and record review, the facility failed to utilize their grievance process to ensure concerns and grievances expressed by members of the Resident Council were responded to and/or followed up in a timely manner for 2 of 7 sampled residents (Residents 35 and 59) reviewed for Resident Council. This failure placed the residents at risk for a diminished quality of life and loss of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications were adequately accounted for, following accepted standards of practice in 3 of 3 controlled medication ledgers reviewed. This failure placed residents at risk of misappropriation of controlled substances and a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record showed an accurate account of a resident's fluid intake while on a fluid restriction for 1 of 3 sampled residents (Resident 180) reviewed for nutrition and hydration. This failure placed the resident at risk of dehydration, fluid overload, and rehospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 77) reviewed for tube feeding (TF, the delivery of nutrients through a tube directly inserted into the stomach) received their nutrition according to provider orders. This failure placed the resident at risk of nutritional complications, dehydration, or fluid overload.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.