Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of South Hill during CMS and state inspections, most recent first.
A resident with a chronic Foley catheter and on anticoagulant therapy experienced significant bleeding and infection following a catheter change that was not performed or documented according to professional standards. The resident developed hematuria, a urethral tear, and acute blood loss anemia, ultimately requiring hospital transfer and transfusion. Staff and documentation did not consistently meet required protocols for catheter care and monitoring.
A resident with atrial fibrillation was not administered an ordered anticoagulant medication due to a transcription error in their EHR. This oversight led to the resident experiencing stroke-like symptoms and requiring an emergency hospital transfer. The facility's staff acknowledged the error as significant.
The facility failed to include necessary services in the care plans for three residents, leading to a risk of unmet needs. A resident with ankylosing spondylitis and pneumonia had a fluid restriction order not reflected in their care plan. Another resident with anemia, diabetes, hyperkalemia, and chronic kidney disease was on a fluid restriction, but this was not documented in their care plan. Additionally, a resident with arthritis, paroxysmal atrial fibrillation, and COPD had a deep tissue injury and a wound, but their care plan only addressed the risk for skin integrity issues, not the actual impairments.
The facility failed to monitor and document bowel movements and implement the bowel program for three residents, leading to a deficiency in care. Despite having provider orders for constipation treatment, residents experienced lapses in receiving necessary medication. Interviews with staff confirmed that LNs should have administered the medication when more than 72 hours had passed without a bowel movement.
The facility failed to monitor fluid intake and transcribe dietary orders for two residents, leading to potential health risks. One resident with CHF had untracked dietary fluids and no system to total intake, while another resident with anemia and diabetes had conflicting fluid restriction orders and inadequate documentation. Staff interviews revealed deficiencies in monitoring and documentation practices.
The facility failed to implement non-pharmacological interventions (NPI) before administering pain medications to five residents, leading to the risk of unnecessary medication use. Residents with conditions such as fractures, amputations, and osteomyelitis received pain medications like oxycodone and acetaminophen without documented NPI attempts, as required by their care plans. Staff interviews confirmed that NPI should have been documented and attempted prior to administering narcotic pain medications.
The facility failed to timely monitor adverse side effects and target behaviors for three residents prescribed psychotropic medications for depression. Monitoring for one resident was delayed by over a month, while another resident's monitoring was delayed by several days. Additionally, incomplete documentation and delayed monitoring for side effects were noted for a third resident. Staff interviews revealed a lack of awareness and oversight regarding timely implementation of behavior monitoring protocols.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with chronic wounds and indwelling devices, as well as to track infectious organisms in their logs for two months. A resident with a chronic wound and another with a urinary catheter did not have EBP signs or PPE supplies, and infections like disseminated shingles and a UTI were not logged.
A facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate antibiotic use for a resident with a UTI. The resident was prescribed cefdinir, but culture results showed resistance, necessitating a change to ciprofloxacin. The Infection Preventionist did not review lab results, relying on the provider's judgment, contrary to facility policy. The DON expected the Infection Preventionist to review infections and lab results, highlighting a gap in the facility's antibiotic stewardship efforts.
A facility failed to provide timely information on formulating an advanced directive for a resident. The resident was admitted, and the social services department contacted the resident's representative 20 days later. The Social Service Assessment had the advanced directive section blank, and the care plan lacked this information. The Social Service Director admitted that the information was provided 13 days after admission, not meeting expectations. The Administrator confirmed that residents should be asked about their advanced directive status within 48 hours of admission.
A resident with COPD and chronic respiratory failure was inaccurately assessed in the MDS as not receiving oxygen therapy, despite continuous use of oxygen at two liters per minute via nasal cannula since admission. Observations, interviews, and EHR documentation confirmed the resident's oxygen use, and staff acknowledged the coding error, which required modification.
A resident's care plan development was delayed as the initial care conference was held 20 days after admission, contrary to the facility's expectation of conducting it within 72 hours. Interviews with the Social Service Director and Administrator confirmed the delay.
A facility failed to administer enteral nutrition according to orders for a resident with dysphagia, leading to a lack of documentation and potential inadequate nutrition. The resident's weight declined, and staff did not document the total tube feed in the EHR. The RD's recommendation to adjust the feeding schedule was not implemented timely.
A facility failed to provide proper respiratory care for a resident with COPD and chronic respiratory failure. The resident was receiving oxygen therapy without documented physician orders or a care plan, and the oxygen tubing was not dated. Staff interviews confirmed the lack of proper documentation and maintenance, which did not meet facility expectations.
The facility did not update nursing staff postings daily to reflect actual hours worked, as observed during a survey. Staff interviews revealed that postings were not updated each shift, contrary to expectations, leading to incomplete information about available nursing staff.
The facility failed to notify the SLTCO of transfers for two residents, one with shingles and another with anemia and diabetes, compromising their access to advocacy and rights information. The administrator confirmed the lack of documentation for these notifications.
The facility failed to provide written bed hold notices to residents during hospital transfers, affecting four residents. Despite expectations to offer and document bed holds, staff interviews and EHR reviews confirmed the absence of such documentation. This deficiency involved residents transferred for various medical reasons, including shingles and an infected surgical implant.
Two residents experienced significant delays in receiving pain medication, with one waiting up to three hours and another reporting multiple instances of delays. Despite these documented concerns, the facility failed to report the alleged violations to the State Agency as required by their policy.
The facility failed to investigate alleged violations of delayed pain medication administration for two residents. One resident experienced a four-hour delay, while another reported a three-hour delay and poor customer service from a staff member. The facility did not document or investigate these incidents, as confirmed by the DON.
A resident did not receive their ordered bedtime medications due to issues with order entry timing, and there was no documentation of medication removal or issues in progress notes. Later, the resident's discharge was delayed, and they requested to hold routine medications after taking a reversal medication. The nurse did not administer the medications at the requested time, and there was no documentation of physician notification or consultation. Staff acknowledged the need for proper documentation and communication with the physician.
A facility failed to implement a personalized discharge plan for a resident with a pelvic fracture, who was discharged without home health services or a primary care provider (PCP) follow-up. Despite plans for community service referrals, including home health therapy and PCP appointments, the resident was discharged without these services. Interviews revealed that the home health agency had no record of receiving a referral, and the Social Services Director admitted the resident fell through the cracks due to staffing issues.
Failure to Follow Professional Standards During Indwelling Catheter Care Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with a chronic indwelling urinary catheter received care and treatment in accordance with professional standards of practice. The facility's policy required staff to document specific details after catheter insertion, including the date and time, catheter size and type, amount of sterile water used, urine characteristics, any complications, practitioner notifications, prescribed interventions, and patient teaching. However, documentation and care practices did not consistently meet these standards during the resident's stay. The resident, who had a history of bladder cancer, chronic catheter use, and was on anticoagulant therapy, experienced multiple episodes of hematuria and bleeding associated with catheter changes. After a catheter change, the resident developed significant bleeding from the penis, which continued despite removal and reinsertion of the catheter. The provider noted that the bleeding was most likely due to trauma from incorrect catheter insertion. The resident subsequently developed symptoms of infection, including fever, flank pain, and low oxygen saturation, and was diagnosed with a urinary tract infection and likely pyelonephritis. Despite ongoing monitoring and interventions, the resident's condition worsened, with continued bleeding, pain, and the development of acute blood loss anemia. The resident was eventually transferred to the hospital, where a urethral tear and laceration were confirmed, and a blood transfusion was required. Staff interviews confirmed awareness of the bleeding and complications following the catheter change, and documentation did not consistently reflect adherence to professional standards for catheter care and monitoring.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to provide an ordered anticoagulant medication to a resident, identified as Resident 27, which was significant to their health. Resident 27 was admitted with diagnoses including atrial fibrillation, a condition that increases the risk of blood clots, and was supposed to continue taking an anticoagulant medication as per hospital discharge orders. However, from the time of admission until the resident's transfer to the hospital, the facility did not transcribe the anticoagulant medication into the resident's electronic health record (EHR), resulting in the resident not receiving the medication. As a result of not receiving the anticoagulant, Resident 27 experienced stroke-like symptoms, including face drooping, left-sided weakness, and left eye dilation, which necessitated an emergent transfer to the hospital. The hospital's emergency department contacted the facility multiple times to inquire about the anticoagulant medication, revealing that the resident had not been administered the medication as ordered. This oversight was identified as a significant medication error by the facility's staff, including the Administrator and the Director of Nursing Services.
Removal Plan
- Audits of all newly admitted residents for hospital order transcription
- In-servicing of staff on transcribing hospital orders
- Ongoing audits of all newly admitted residents for hospital order transcription
- Referral to the Quality Assurance and Performance Improvement program for ongoing monitoring
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to include necessary services in the care plans for three residents, leading to a risk of unmet needs and diminished quality of life. Resident 40, admitted with ankylosing spondylitis and pneumonia, had a provider's order for a fluid restriction, but this was not reflected in their care plan. Both a Licensed Practical Nurse and the Director of Nursing Services confirmed the absence of this critical information in the care plan, acknowledging it did not meet expectations. Similarly, Resident 42, who was readmitted with conditions including anemia, diabetes, hyperkalemia, and chronic kidney disease, was on a fluid restriction as per provider orders. However, their care plan lacked documentation of this restriction. A Registered Nurse confirmed that the fluid restriction should have been included in the care plan. Additionally, Resident 226, with arthritis, paroxysmal atrial fibrillation, and COPD, had a deep tissue injury and a wound on the buttock, but their care plan only addressed the risk for skin integrity issues, not the actual impairments. A Registered Nurse/Unit Care Coordinator noted the absence of a care plan for the existing skin integrity issues.
Failure to Implement Bowel Program and Document Bowel Movements
Penalty
Summary
The facility failed to consistently monitor and document bowel movements and implement the bowel program as needed for three residents, leading to a deficiency in care. Resident 177, who had a history of heart and kidney disease, diabetes, depression, and anxiety, reported issues with constipation since admission. Despite having provider orders for constipation treatment, there was a nine-day period where no medication was administered. Similarly, Resident 176, with heart disease and depression, had multiple days where no constipation treatment was provided, despite orders and a care plan that included monitoring for constipation as a side effect of antidepressant medication. Resident 40, who had kidney disease, stroke with hemiplegia, and depression, also experienced a lapse in constipation treatment. The resident reported constipation for several days without receiving medication, despite having provider orders for treatment. The facility's policy required documentation of bowel movements and implementation of standing orders for constipation, which was not followed. Interviews with staff confirmed that the licensed nurses should have administered the necessary medication when more than 72 hours had passed without a bowel movement.
Failure to Monitor Fluid Intake and Transcribe Orders
Penalty
Summary
The facility failed to accurately monitor fluid intake and ensure dietary and supplement orders were properly obtained and transcribed for two residents, leading to potential health risks. Resident 40, who was admitted with chronic heart failure, ankylosing spondylitis, and pneumonia, had a fluid restriction order of 2000 ml due to CHF. However, the facility did not track dietary-provided liquids, and there was no system in place to total the resident's fluid intake. Interviews with staff revealed that the monitoring of Resident 40's fluid restriction did not meet expectations, as nursing staff were not totaling or monitoring the total fluid intake, and dietary fluids were not being tracked. Resident 42, who was readmitted with anemia, diabetes, hyperkalemia, and chronic kidney disease, was also on a fluid restriction. The resident's dietary order conflicted with the provider's order, and there was no care plan or interventions documented for fluid restrictions. Staff interviews indicated that fluid intake was not properly documented or monitored, and there was confusion regarding the prescribed fluid restriction amounts. The lack of documentation and monitoring did not meet expectations, and the care plan failed to include necessary fluid restriction orders.
Failure to Implement Non-Pharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPI) before administering pain medications to five residents, leading to the risk of unnecessary medication use. Resident 6, with a diagnosis of a left forearm fracture, had orders for oxycodone with a requirement to attempt NPI first, yet the medication administration record (MAR) showed multiple instances marked as NA for NPI. Similarly, Resident 24, who had a left lower leg amputation, received oxycodone without documented NPI attempts, as indicated by numerous NA entries in the MAR. Staff interviews confirmed that NPI should have been documented and attempted prior to administering narcotic pain medications. Resident 32, diagnosed with respiratory failure, was given acetaminophen without NPI on a specific date, contrary to the provider's orders. Resident 41, with osteomyelitis, had 18 instances of oxycodone administration without NPI documentation. Lastly, Resident 226, suffering from arthritis and spinal stenosis, received both acetaminophen and hydrocodone-acetaminophen without NPI documentation on multiple occasions. Staff interviews revealed that the expectation was for NPI to be offered and documented before administering as-needed pain medications, which was not met, as evidenced by the MAR entries.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to timely initiate monitoring of adverse side effects and target behaviors for three residents who were prescribed psychotropic medications for depression. Resident 24 was admitted with a diagnosis of depression and was prescribed nortriptyline. However, the monitoring for targeted behaviors related to the antidepressant was not initiated until over a month later. Similarly, Resident 276 was prescribed multiple antidepressants, including amitriptyline, trazadone, and sertraline, but the monitoring for targeted behaviors was delayed by several days. Staff interviews revealed a lack of awareness and oversight regarding the timely implementation of behavior monitoring protocols. Resident 226 was also affected by the facility's failure to monitor side effects and target behaviors promptly. This resident was prescribed duloxetine for depression, but the monitoring for side effects was not initiated until eight days after the medication was administered. Additionally, there was incomplete documentation for monitoring target behaviors, with missing entries for the evening shift and a lack of documentation on whether behaviors were exhibited or interventions were offered. Staff acknowledged the errors in documentation and the delay in initiating monitoring, which did not meet the facility's expectations.
Failure to Implement Infection Control Program and Track Infections
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically in the application of Enhanced Barrier Precautions (EBP) for two residents. Resident 5, who had a chronic wound on their left ankle, did not have an EBP sign on their door, and staff were not using gowns and gloves for high-contact care activities. Similarly, Resident 226, who had an indwelling urinary catheter, also lacked an EBP sign and appropriate personal protective equipment (PPE) supplies at their doorway. Interviews with staff, including the Infection Preventionist and the Administrator, confirmed that these residents should have had EBP in place, but it was not implemented. Additionally, the facility failed to track infectious organisms effectively in their infection control logs for August and September 2024. The logs did not include any identified organisms or multidrug-resistant organisms (MDROs) for tracking. Notably, Resident 177, who had disseminated shingles, and Resident 278, who was treated for a urinary tract infection, were not included in the infection control logs. Staff interviews revealed that it was the practice to track all infections and update the logs, but this was not done for the mentioned months.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which is designed to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use. This deficiency was identified during a review of the facility's practices concerning a resident who was admitted with sepsis, obstructive uropathy, and a urinary tract infection (UTI). The facility's policy required an antibiotic time-out at 72 hours after initiation to reassess the need for antibiotics based on lab results and the resident's condition. However, the facility did not adhere to this policy, as evidenced by the case of Resident 26, who was prescribed cefdinir for a UTI. A culture result, which was not reviewed by the facility, indicated the presence of pseudomonas, a multidrug-resistant organism resistant to cefdinir, necessitating a change to ciprofloxacin. The deficiency was further highlighted by the interviews conducted with facility staff. The Infection Preventionist, Staff M, admitted to not reviewing lab or culture results for all UTIs, relying instead on the provider's judgment. This oversight led to the inappropriate continuation of cefdinir, despite the culture results indicating resistance. The Director of Nursing Services, Staff B, expressed that it was their expectation for the Infection Preventionist to review infections and associated laboratory culture results as part of the antibiotic stewardship efforts. This lack of adherence to the facility's policy and failure to review critical lab results placed residents at risk for adverse outcomes associated with inappropriate antibiotic use.
Failure to Timely Address Advanced Directive for a Resident
Penalty
Summary
The facility failed to provide information on formulating an advanced directive for one of the sampled residents, identified as Resident 36. Upon review, it was found that Resident 36 was admitted to the facility, and the social services department contacted the resident's representative to schedule a care conference 20 days after admission. The Social Service Assessment conducted shortly after admission had the advanced directive section left blank, and the care plan also lacked information regarding the resident's advanced directive status. During interviews, the Social Service Director acknowledged that information regarding advanced directives was provided 13 days after admission, which did not meet the facility's expectations. The Administrator confirmed that residents should be asked about their advanced directive status within 48 hours of admission, and the delay in addressing this for Resident 36 did not meet expectations.
Inaccurate MDS Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for Resident 226, which did not accurately reflect the resident's status regarding oxygen therapy. Resident 226 was admitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Despite the resident receiving continuous oxygen therapy at two liters per minute via nasal cannula since admission, the admission MDS inaccurately indicated that the resident was not receiving oxygen therapy. Observations and interviews confirmed that Resident 226 was receiving oxygen therapy, and the electronic health record (EHR) documented the use of oxygen on multiple dates. Staff H, an LPN/MDS Nurse, and Staff B, the Director of Nursing Services, acknowledged the error in coding the MDS and stated that it needed modification. This inaccuracy in the MDS placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Conduct Timely Care Conference
Penalty
Summary
The facility failed to include a resident's input and preferences in the development of their care plan, which was identified during a review of care conferences. Specifically, the facility did not conduct an initial care conference for the resident within the expected timeframe. The resident was admitted to the facility, and the social services department contacted the resident's representative to schedule a care conference, which was held 20 days after admission. This delay did not meet the facility's expectation of holding an initial care conference within 72 hours of admission. Interviews with the Social Service Director and the Administrator confirmed that the care conference for the resident did not meet the expected timeline.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to administer enteral nutrition according to the provider's orders and professional standards for a resident with dysphagia, who required a feeding tube for nutrition. The resident, who had a history of stroke, kidney disease, aphasia, and muscle weakness, was dependent on staff for all activities of daily living. The care plan indicated that the resident was at risk for weight fluctuations and malnutrition, and the registered dietitian was to evaluate and recommend changes to the tube feed as needed. However, the facility did not have a system to ensure the amount of enteral formula received matched the ordered amount, and the licensed nurses did not document the total amount of tube feed administered every shift in the resident's electronic health record. Observations and interviews revealed that the tube feed was temporarily turned off during wound care, and staff were unclear about where to document the total tube feed in the medication administration record. The resident's weight had declined over several weeks, indicating potential inadequate nutrition. The registered dietitian had recommended a change in the tube feed order to prevent continuous feeding for 24 hours, but this change was not implemented within the expected timeframe. The Director of Nursing Services expected the dietitian's recommendations to be followed within 72 hours and for the licensed nurses to document the total tube feed every shift.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. The resident was admitted to the facility with hospital discharge orders indicating the need for oxygen therapy at two liters per minute via nasal cannula. However, the facility did not transcribe or obtain physician orders for this oxygen therapy, nor did they include it in the resident's care plan. Observations showed that the resident was receiving oxygen therapy, but the tubing was not dated, indicating a lack of maintenance and regular change. Interviews with facility staff revealed that there were no orders for the resident's oxygen therapy, and it had not been care planned as required. The Director of Nursing Services acknowledged that the orders for oxygen therapy should have been initiated and care planned upon the resident's admission. This oversight placed the resident at risk for unmet needs and potential negative outcomes due to the lack of proper documentation and maintenance of the oxygen therapy equipment.
Failure to Update Nursing Staff Postings
Penalty
Summary
The facility failed to ensure that the nursing staff posting was updated daily to reflect the actual nursing staff hours worked during the survey period. Observations on multiple occasions revealed that the nursing staff postings did not include the actual hours worked, with the forms left blank. On one occasion, the posting was dated with the previous day's date and did not show the actual nursing staff hours. This lack of accurate and timely information prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff. Interviews with staff members revealed inconsistencies in the process of updating the nursing staff postings. The Staffing Coordinator admitted to not updating the forms to reflect actual hours worked until the next morning if there were no call-offs, rather than updating them each shift. The Administrator confirmed that the expectation was for the postings to be updated at the beginning of every shift to include actual worked hours. However, this expectation was not met, as evidenced by the incomplete postings for several days during the survey period.
Failure to Notify SLTCO of Resident Transfers
Penalty
Summary
The facility failed to properly notify the Office of State Long-Term Care Ombudsman (SLTCO) of discharges for two residents, which is a requirement to ensure residents have access to advocacy and are informed of their rights. Resident 177 was transferred to a local medical center for treatment of shingles, a condition associated with a compromised immune system, but the SLTCO was not notified of this transfer. The resident's electronic health records confirmed the transfer date, and during an interview, the facility's administrator acknowledged the lack of documentation regarding the notification to the SLTCO. Similarly, Resident 42 was transferred to a hospital for treatment of anemia and diabetes but was readmitted to the facility without the SLTCO being informed of the initial transfer. The discharge and entry tracking records confirmed the transfer and readmission dates. The facility's administrator also confirmed the absence of documentation for notifying the SLTCO about Resident 42's transfer. These oversights in communication with the SLTCO were identified during interviews and record reviews, highlighting a deficiency in the facility's discharge notification process.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of transfer to a hospital, as required by regulations. This deficiency was identified for four residents who were transferred to hospitals for various medical reasons, including treatment for shingles, an infected surgical implant, and other health issues. The absence of bed hold notices was confirmed through interviews with the residents and staff, as well as a review of the residents' electronic health records (EHRs), which showed no documentation of bed hold offers or discussions. Resident 177, who was transferred for shingles treatment, reported not receiving a bed hold notice, and staff interviews confirmed the lack of documentation in the EHR. Similarly, Resident 27 was transferred to a hospital without a bed hold notice, as confirmed by the Medical Records Director. Resident 42 and Resident 47 also did not receive bed hold notices during their hospital transfers, with staff unable to locate any documentation in their EHRs. The facility's staff, including the Business Office Manager, LPN/Unit Care Coordinator, and Director of Nursing Services, acknowledged the expectation to offer and document bed holds, but this was not met in these cases.
Failure to Report Delayed Pain Medication Administration
Penalty
Summary
The facility failed to implement its abuse prohibition policy for two residents, leading to a deficiency in reporting alleged violations to the State Agency (SA). Resident 10, who had multiple fractures and an anxiety disorder, experienced a significant delay in receiving pain medication. Despite requesting pain relief at 1:30 AM, the medication was not administered until 4:29 AM, three hours later. This delay was documented by Resident 10's collateral contact, but the facility did not report this alleged violation of delayed care to the SA as required by their policy. Similarly, Resident 11 reported a pattern of poor customer service and delays in pain medication administration by the same staff member, Staff L. Resident 11 experienced wait times of up to three to four hours for pain medication on multiple occasions. Despite these concerns being documented, the facility again failed to report the alleged violation to the SA. The Director of Nursing acknowledged that the facility should have reported these concerns but did not, resulting in a failure to comply with state regulations.
Failure to Investigate Alleged Violations of Delayed Pain Medication
Penalty
Summary
The facility failed to implement its abuse prohibition policies and procedures for two residents who were reviewed for abuse. Specifically, the facility did not conduct a thorough investigation or maintain documentation of alleged violations involving delayed administration of pain medication. Resident 10 experienced a four-hour delay in receiving pain medication after requesting it from a registered nurse, which was documented by a collateral contact. The facility's reporting log did not show that this alleged violation was reported or investigated. Similarly, Resident 11 reported concerns about a staff member's poor customer service and a three-hour delay in receiving pain medication. Again, the facility's reporting log lacked documentation to indicate that this alleged violation was recognized or investigated. Interviews with the Director of Nursing confirmed that the facility did not conduct or document thorough investigations of these alleged violations, as required by their policies and state guidelines.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for Resident 3, particularly in the area of medication administration. On the day of admission, Resident 3 did not receive their ordered bedtime medications, including those for chronic pain, due to issues with the timing of order entry into the computer system. The Medication Administration Record (MAR) indicated that some medications were documented as administered, but there was no evidence of them being removed from the Omnicell or any documentation of issues in the progress notes. The Director of Nursing confirmed that the medications should have been removed for Resident 3 but were not. On another occasion, Resident 3's discharge was delayed due to an abnormal lab result, and a reversal medication was ordered. Resident 3 decided to follow online recommendations to hold routine medications for six hours after taking the reversal medication. However, the nurse did not administer the routine medications at the requested time, and there was no documentation of the physician being notified of Resident 3's request or refusal to take medications at the scheduled time. The MAR did not reflect any orders to hold the routine medications, and the nurse progress notes lacked documentation of the physician's consultation regarding the medication timing. The facility's staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing, acknowledged that the physician should have been notified of Resident 3's medication timing requests and that it was inappropriate to document the medication as refused if the resident was willing to take it at a different time. The lack of proper documentation and communication with the physician contributed to the deficiency in medication administration for Resident 3.
Failure to Implement Personalized Discharge Plan
Penalty
Summary
The facility failed to implement a personalized discharge plan for Resident 2, who was reviewed for discharge planning. Resident 2, who had no cognitive problems and was diagnosed with a fracture of the pelvis, planned to discharge back to the community and move in with a family member. The discharge care plan included interventions for social services to make community service referrals, including home health services, primary care provider (PCP) follow-up appointments, and ordering durable medical equipment needed for discharge. However, a psychosocial progress note indicated that Resident 2 did not have a PCP, and a referral was sent to a named home health agency (HHA-1) for home health therapy and a GAP provider to assist with obtaining a PCP. Despite these plans, a state agency referral showed that Resident 2 was discharged home without home health services. Interviews revealed that HHA-1 had no record of receiving a referral for Resident 2, and the Social Services Director acknowledged that Resident 2 fell through the cracks due to being short-staffed at the time. The Director of Nursing confirmed that the referral for home health and PCP services was not received by HHA-1, indicating that Resident 2 likely did not have timely PCP follow-up care or home health therapy services, which did not meet the facility's expectations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Puyallup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Puyallup Post Acute | 0.1 mi | — | 36 | 0 |
| Rainier Rehabilitation | 1 mi | — | 0 | 0 |
| Life Care Center Of Puyallup | 1 mi | — | 22 | 0 |
| Linden Grove Health Care Center | 2.5 mi | — | 45 | 0 |
| Heartwood Extended Healthcare | 5.9 mi | — | 30 | 0 |
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