Roanoke Rehabilitation & Healthcare Center

Based on observations, interviews, and policy review the facility failed to ensure food service employees washed their hands before they put on clean gloves. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: Review of the facility's policy titled, Hand and Single Use Glove Sanitation Practices, revised in October 2017, indicated . Facility employees shall follow sanitary practices when handling food to prevent the spread of foodborne illness . The policy specified food service employees wash their hands after the following activities, . viii. Touching garbage or trash can . xii. Before putting on gloves and after removing gloves . On 09/19/2023 beginning at 11:21 AM, the surveyor observed [NAME] #1 pick gloves up off the floor and apply new gloves without washing her hands. [NAME] #1 then proceeded to make a turkey sandwich for a resident. After the turkey sandwich was made, [NAME] #1 removed her gloves and applied clean gloves without washing her hands. [NAME] #1 was noted to touch the lid of the trash can when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, document review, and interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) for one of one sampled resident reviewed for resident assessments. Findings included: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, specified, . The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored . A review of Resident #16's Face Sheet indicated the facility admitted the resident on 01/06/2015. A review of Resident #16's medical record, revealed the last completed Minimum Data Set (MDS) was a quarterly MDS with an Assessment Reference Date (ARD) of 04/10/2023. During an interview on 09/19/2023 at 10:55 AM, the MDS Coordinator indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to ensure staff transcribed wound care orders for one (Resident #154) of 16 sampled residents. The failure to transcribe the wound care orders resulted in staff not performing wound care as ordered. Findings included: The facility policy titled, admission of a Resident, effective on 02/01/2004 indicated, . Purpose: The admission process is intended to obtain all the information possible about the resident for the development of [the] comprehensive plan of care and to assist the resident in becoming comfortable in the facility . The facility policy titled, Wound and Skin Care Protocols, dated October 2010, specified, . Objectives: To maintain skin integrity and promote wound healing. General Policy: These protocols are designed as a guide to the prevention and/or treatment of impaired skin integrity. They are intended to serve as a tool in the appropriate management of preventative skin care and the management of actual impaired skin.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, discussion during the resident group meeting, review of the facility's admission Agreement, and review of scheduled mail delivery days and times through the United States Postal Service (USPS) website, the facility failed to ensure mail was delivered to residents on Saturdays. This deficient practice had the potential to affect all 54 out of 54 residents residing in the facility. Findings Include: A review of the facility's, admission AGREEMENT, with a revised date of 10/08/2014, revealed: . RESIDENT'S RIGHTS .13. Resident rights .(i) Mail. The resident has the right to privacy in written communication, including the right to- (1) send and promptly receive mail that is unopened, . On 03/02/22 at 10:45 AM a group meeting was held with nine residents present. All nine residents confirmed that they do not receive mail on Saturdays. Resident Identifier (RI) #30 stated the facility's Business Office was not open on Saturdays so there was no one to get the mail from the post office. According to RI #30, the mail that should be delivered on Saturdays is held and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of facility policies, titled STORAGE OF REFRIGERATED FOODS, STORAGE OF FROZEN FOOD and FOOD SERVICE OPERATIONAL STANDARDS FOR PURCHASING, RECEIVING, COOKING AND STORAGE OF FOOD, the facility failed to ensure that all food items in the kitchen cooler/freezer were labeled with an open and use by date, and that food items were discarded when the use-by-date was exceeded. This had the potential to affect 49 of 49 residents who received meals from the kitchen. Findings include: Review of facility's policy titled STORAGE OF REFRIGERATED FOOD, with a revised date of 10/17, revealed: POLICY: The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. PROCEDURE: .5. All opened foods are labeled with common name of food, date stored and use- by date . Review of facility's undated policy titled STORAGE OF FROZEN FOOD revealed: POLICY: The facility ensures the quality and safety of frozen food through accepted storage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #1's discharge Minimum Data Set (MDS) was signed off as completed by a Registered Nurse (RN). This deficient practice affected one of 16 sampled residents whose MDS assessments were reviewed. Findings include: A review of the CMS, Long-Term Care Resident Assessment Instrument 3.0 User's Manual, dated of October 2019, revealed: .09. Discharge Assessment-Return Not Anticipated . Must be completed .within 14 days after the discharge date . RI #1 was admitted to the facility on [DATE] and discharged on 01/17/22. Review of RI#1's discharge MDS assessment revealed, . STATUS: Open . discharge date [DATE] . On 03/03/22 at 10:50 AM, an interview was conducted with Employee Identifier (EI) #4, MDS Coordinator. EI #4 was asked when RI #1 was discharged from the facility. EI #4 said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and review of the facility policy titled Eye Ointment/Drops Administration, the facility failed to ensure a licensed staff member did not place the eye drop bottle in her pocket after giving Resident Identifier (RI) #25 scheduled eye drops. This was observed on 3/2/22 and affected one of two residents observed receiving eye drops during medication administration. Findings include: A review of the facility policy titled Eye Ointment/Drops Administration, with an effective date of February 1, 2004, revealed: . PROCESS . 11. Administer medication .14. Replace medication cap 15. Return to medication cart . RI #25 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #25 had a diagnosis of Dry Eye Syndrome. A review of RI #25's March 2022 Physician orders revealed . COSOPT EYE DROPS -GIVE 1 GTT (DROP) TO RIGHT EYE TID (three times a day) . On 3/02/22 at 4:27 PM, Employee Identifier (EI) #3, Registered Nurse (RN), was observed giving RI #25's scheduled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, medical record review, and review of the facility's policy titled, Bath - Shower or Tub, the facility failed to ensure Resident Identifier (RI) #43 was not exposed while being transported back to his/her room after a shower on 5/8/19. This affected one of sixteen residents sampled. Findings Include: A review of the facility's policy titled, Bath - Shower or Tub, with an Effective Date of February 1, 2004 revealed: . PURPOSE: Shower and tub baths promote cleanliness and comfort for the resident. PROCESS: b) Drape the resident and transport to the bath area. c) Assist the resident the bath or shower keeping them draped . e) Assist resident out of the tub or shower and into the chair . h) Dress the resident RI #43 was re-admitted to the facility with diagnoses to include Cerebral Infarction, Schizophrenia, and Generalized Anxiety Disorder. On 5/8/19 at 10:15 AM, two surveyors observed RI #43 in shower chair, being wheeled from the whirlpool room to his/her room, with right side of buttocks and thigh exposed. Nursing staff and male and female residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #53 did not fall off the bed in September 2019 when only one Certified Nursing Assistant (CNA) was assisting with bed mobility. This affected one of one sampled resident reviewed for falls. Findings include: RI # 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Vascular Dementia with Behavioral Disturbances, Obsessive-Compulsive Personality Disorder, and Quadriplegia. RI #53's quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 7/17/18 documented RI #53 was cognitively intact, required extensive assistance of two people for bed mobility, and had impaired range of motion on both sides to both upper and lower extremities. RI #53's comprehensive care plans included a care plan for Requires extensive to total assist with ADL's (Activities of Daily Living) related to quadriplegia, h/o (history of) cva (cerbrovascular accident), spinal cord injury ., onset date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of a facility policy titled Urinary Catheter Care, the facility failed to ensure a licensed nurse did not wipe Resident Identifier (RI) #49 from back to front multiple times up to his/her catheter. This affected one of three residents sampled for catheters. Findings include: Review of the facility policy titled Urinary Catheter Care, effective 2/01/04, revealed the following: PURPOSE: Urinary catheter care helps to prevent urinary tract infection. STANDARD: Catheter care should be provided each time perineal care is provided . PROCESS: . II. Catheter Care a) Wash perineal area per policy b) Cleanse area of catheter insertion well using soap and water . c) Wash the catheter itself by holding on to the catheter at the insertion site; wash with one stroke downward . d) Rinse perineal area well and rinse the catheter by holding on to the insertion site; rise with one stroke downward . RI # 49 was admitted to facility on 4/4/18 and re-admitted [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, review of a facility policy titled Administering Medications via Nasogastric / Gastrostomy Tube and review of the manufacturer's protocol for use Enteral Feeding Tube DeCloggers, the facility failed to ensure: 1) Licensed staff did not allow the tip of the DeClogger to come in contact with Resident Identifier (RI) #34's bed linens, prior to insertion into the gastrostomy tube; 2) Licensed staff rinsed and dried RI #34's syringe and plunger, and placed into a labeled bag after mediction administration via gastrostomy tube; 3) Licensed staff mixed crushed medications with water prior to administering to RI #34 via gastrostomy tube; and 4) Licensed staff used the DeClogger device to unclog RI #34's gastrostomy tube in accordance with the manufacturer's protocol for use. These failures affected RI #34, one of one resident observed during administration of medications per gastrostomy tube. Findings include: A review of the facility's policy titled, Administering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.