Roane General Hospital

Based on record review and staff interview the facility failed to ensure that every resident's medication regimen is managed safely and effectively wth medical indications included. This is true for one (1) of five (5) residents reviewed for unnecessary medicaltions. Resident Identifier: #48 Facility Census: 32 Findings include:a) Resident #48On 09/24/25 at 10:48 AM during record review of unnecessary medications it was noted that two (2) currently ordered medication for Resident #48 did not have indications as to why the resident was prescribed the medications.The orders are as followsFurosemide 40mg Tablet (Lasix) daily, ordered 11/04/22 Citalopram hydrochloride (Celexa) 20 mg daily, ordered 09/12/23Neither order had a medical indication under problem to indicate the reason the resident is on these medications.It was confirmed with the Director of Nursing on 09/24/25 at 3:00 PM that the omission of indicators should have been caught during the pharmacy Medication Regimen Review at which time she agreed.

Based on record review and interview, the facility failed to ensure that a resident was offered the option to receive or decline the COVID vaccine. Furthermore, the resident was not provided with the appropriate education about the COVID vaccine. This was true for one (1) of eighteen (18) residents sampled. Resident Identifier: #10. Facility Census: 32.a) Resident #10Findings IncludeDuring a review of immunization records on 09/24/25 at approximately 3:00 PM, it was revealed that the facility had no records of COVID education, or a COVID vaccine being offered to Resident #10.During an interview with the Infection Preventionist (IP) on 09/24/25 at approximately 1:15 PM, IP stated that she did not have any records, consents, or declinations for the COVID vaccine for Resident #10.

Based on observation and staff interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. It was discovered during the kitchen tour that a stand-alone warming unit was dirty. The deficient practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 35. Findings included: a) Kitchen tour During the kitchen tour, on 12/04/23 at 12:15 PM, an observation revealed a warming unit needed to be cleaned. Crusted food particles were on the ledge of the door opening. In an interview and observation on 12/04/23 at 12:25 PM, the Certified Dietary Manager (CDM) verified the warming unit needed cleaned. .

Based on observation, policy review and staff interview, the facility failed to provide hand hygiene to prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident Identifiers: #6, #19, #27, #30. Facility Census: 35 Findings included: a) On 12/04/23 at 12:20 PM it was observed that staff was passing the lunch meal trays in the dining room without providing hand hygiene for the Residents #6, #19, #27 and #30. On 12/04/23 at 12:38 PM this was confirmed by Nurse Aide (NA) #27 who stated they usually pass warm, wet wash cloths to residents to perform their own hand hygiene. She further stated that she did not know why they did not pass them on this day. At this time, the Registered Nurse (RN), [NAME] President of Nursing #32 came into the dining room and the finding was confirmed with her as well and she instructed staff to pass the washcloths. b) Hand hygiene during medication pass During a random opportunity for discovery, on 12/05/23 at 8:45 PM, Licensed Practical Nurse (LPN) #39 dropped a container of…

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 and staff interview the facility failed to ensure a dignified dining experience for two (2) residents. Two (2) residents were not served their meal at the same time as the other residents sitting at their table. Resident identifiers: #19, and #25. Facility census: 35. Findings included: a) Resident #19 During an observation on 12/04/23 at 12:45PM Resident # 19 was seated at the table that was served third in the dining room. Four (4) other residents were seated at the same table. Two (2) of the residents were given their lunch tray at 12:45PM, then the next table was served. Resident #19 did not get his tray until 1:00PM During an Interview, on 12/04/23 at 12:47PM, Nursing Assistant (NA) #65, She stated, We usually do serve the trays in order, but some days they get mixed up. They are mixed up today. During an interview on 12/04/23 at 12:50PM with staff member Licensed Practical Nurse (LPN) # 39, she stated, They are not in order today. I'm not sure why. A review 12/04/23 at 2:00PM of the facilities Meal Service policy reads under procedure number 8 {Nursing…

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 and staff interview, the facility failed to ensure residents had reasonable accommodation of needs by not providing access for the residents to turn over bed lights on and off on own. This failed practice was found to be true for four (4) of six (6) residents. Resident identifiers: #12, #6, #13, and #236. Facility census 35. Findings included: a) Resident #12 During an observation on 12/04/23 at 1:15 PM of Resident #12's room revealed that Resident #12's room was not arranged in a fashion in which Resident #12 could turn on/off their own over the bed light. During an interview, on 12/05/23 at 1:57 PM, with Nurse Aide (NA) #27 the NA stated, The residents with the long strings usually ask for them. The others just ring their call bell and we turn it on and off for them. Resident #12 uses the call light so they should be able to turn the light on and off. During a record review on 12/05/23 at 3:00 PM of Resident #12's care plan revised on 08/02/23 has not mention of Resident #12 not being able to turn on the bed light themselves. b) Resident #6 An observation on…

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, resident interview and staff interview the facility failed to establish a grievance policy which included the required information. The facility's grievance policy failed to include the contact information of the grievance official with whom a grievance can be filed. This was a random opportunity for discovery. Facility census: 35. Finding included: a) Resident Council During a meeting with the facilities Resident Council on 12/05/23 at 11:00 AM the resident group indicated they are not sure who to file a grievance with and they just tell whoever will listen. During a review on 12/05/23 at 2:00 PM of the facilities Resident Complaint policy there was no name or contact information for the person they would file a grievance with. During an interview, on 12/06/23 at 9:30 AM, with Director of Nursing (DON) the DON stated, The social workers office is upstairs. If a resident has a complaint, we put the form in her box for her to pick up. The DON confirmed the social workers contact information was not on the policy. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to initiate a significant change Minimum Data Set (MDS) when a resident was ordered Hospice services and had less than six (6)months to live. This was true for one (1) of two (2) residents reviewed for Hospice. Resident identifier: #35. Facility census: 35. Findings included: a) Resident #35 On [DATE] at 10:07 AM a medical record review found Resident #35 had a change in condition when the resident experienced a major Cerebral Vascular Accident (CVA). This resident was placed on Hospice services on [DATE]. A review of the Minimum Data Set (MDS) found Death in Facility tracking was completed on [DATE]. A significant change in condition MDS was not completed when the resident was placed on Hospice. Resident #35 died on [DATE]. During an interview with the MDS Coordinator on [DATE] at 10:45 AM the coordinator stated that it was too late to do a significant change MDS because of the short time span between returning to facility and date of…

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 medical record review and staff interview, the facility failed to ensure care plans were resident centered and complete. Resident #35's care plan was not updated to reflect hospice services. Resident #10's care plan did not include the name of the hospice and contact information for the hospice agency. Resident #16's care plan had not been updated to reflect a change in the need to contact the physician for blood glucose levels. Resident #18's care plan did not include the pressure ulcer the resident had. Resident identifiers: #35, #16, #18, #10. Facility census: 35. a) Resident #35 On [DATE] at 1:11 PM a review of the medical record found no evidence of a care plan for hospice. The facility care plan was not updated to reflect the resident was ordered hospice services. The Hospice organization assessments and care plans of 40 plus pages had to be faxed over to the nursing facility. The NHA stated that the documents were scanned into the electronic medical record. The hospice service was started on…

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, policy review and staff interview, the facility failed to follow the procedure for neurological checks for an unwitnessed fall. This was true for one (1) of two (2) falls reviewed. Resident identifier: #25. Facility census: 35. Findings included: a) Resident #25 On 12/04/23 at 3:10 PM record review shows Resident #25 had an unwitnessed fall on 11/21/23 and there were no neurological checks performed after the fall. According to facility Policy for Charting Guidelines - Falls: When a fall occurs, it is necessary to assess the resident and begin documentation per the Falls guidelines to reduce the chance that an undetectable injury may be present. It states the process as follows: Neuro checks initially and EVERY 4 HOURS for 24 hours. This was confirmed with the Registered Nurse (RN), [NAME] President of Nursing #32 on 12/05/23 at 12:38 PM when she stated staff should have completed neurological checks for 24 hours after the fall occurred.

Based on observation and staff interview, the facility failed to ensure all drugs were labeled in accordance with currently accepted professional principles. It was discovered in the medication storage refrigerator that a box of insulin for Resident #8 had not been labeled with the resident's name. This failed practice had the potential to affect any resident receiving medication from the medication storage refrigerator. Resident identifier: #8. Facility census: 35. Findings included: a) Medication storage refrigerator During an observation, on 12/06/23 at 9:00 AM, of the medication storage refrigerator. It was discovered the box containing the Humulin R vial was not labeled with Resident #8's name. In an interview on 12/06/23 at 9:05 AM with the Minimum Data Set (MDS) Coordinator, verified the box of Humulin R had not been labeled with Resident #8's name. .

Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. This was true for one (1) of 16 residents who had physician orders reviewed during the Long-Term Care Survey Process. There were incomplete physician's orders for hospice services. The orders did not include the name of the contracted hospice service provider or their contact information for Resident #10. Resident identifier: #10. Facility census: 35. Findings included: a) Resident #10 During a medical record review, on 12/05/23, it was noted the orders for hospice services did not include a service agency or any contact information. In an interview with the Director of Nursing (DON) on 12/05/23 at 12:40 PM, verified the orders for hospice services were incomplete. The orders did not include the agency providing the hospice services or the contact information. .

Based on observation and staff interview, the facility failed to maintain a wheelchair in good working order. This was a random opportunity for discovery. Resident identifier: #15. Facility census: 35. Findings included: a) Resident #15 On 12/05/23 8:50 AM an observation of the wheelchair handles revealed they were covered with pink tape. The tape had multiple tears and shredded pieces. The ends of the brakes were open. The brake handles could not be cleaned and had the potential for injury. During an observation with the Director of Nursing (DON) at this same time the DON agreed the brake handle needed new covers. These were replaced on 12/05/23.

Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This practice has the potential to affect all residents residing in the facility. Facility census: 33. Findings included: a) Medication Regimen Review Policy The facility policy titled Consultant Pharmacy Services Provided to Skilled Nursing Facility was given to the survey team on 05/17/22. The Medication Regimen Review (MRR) policy lacks time frames for the different steps in the review process and does not identify the steps the pharmacist must take when identifying an irregularity that requires urgent action to protect the resident. The Assistant Director of Nursing (ADON) reviewed the MRR policy during an interview on 05/17/22 at 3:12 PM. The ADON confirmed the MRR policy lacks time frames for the different steps of…

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 and staff interview, the facility failed to ensure three (3) of 13 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Residents #4, #29 and #133 had incomplete Physician Orders for Scope of Treatment (POST) forms. Resident identifiers: #4, #29, and #133. Facility Census: 33. Findings included: a) Resident #4 A brief electronic health record review was completed on 05/16/22 at 2:23 PM. A POST form was on file. In Section F of the POST form there was no phone number provided for the physician. A review of the 2021 Using the POST form Guidance for Health Care Professionals states, Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview on 05/17/22 at 12:40 PM, the Director of Nursing (DON) reported the physician's phone number should have been given and leaving it blank was an error. The DON further stated the POST form will be updated. b) Resident #29 A brief electronic…

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 and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. room [ROOM NUMBER] had two (2) areas of bubbling paint below the television. The bottom of Resident #18's closet door was missing the wood laminate leaving the wood surface exposed. Additionally, the facility failed to keep the dining room temperature at a comfortable temperature level. These were random opportunities for discovery. Room identifiers: 117-A and 123. Resident identifiers: #3, #18, #6. #10, #12, #15, #22, #27, and #28. Facility census: 33. Findings included: a) room [ROOM NUMBER] Observation, on 05/16/22 at 11:46 AM, found two (2) areas of bubbling paint on the wall just below the television. One area was approximately the size of a softball. The other area was approximately the size of a tennis ball. During an interview, on 05/17/22 at 11:47 AM, the Director of Nursing (DON) stated, This definitely should have been addressed and repaired. I will see that it gets done. b)…

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 and staff interview, the facility failed to ensure resident inhalers were protected from contamination. In addition, nursing staff failed to wash turn off the water faucet with a dry paper towel after washing their hands and the laundry table was in disrepair and could not be cleaned. These practices had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #1 and #133. Facility census: 33. Findings included: a) Inhalers In addition, LPN #7 took two (2) inhalers into R#1's room and placed them on the over bed table. LPN #7 administered one (1) inhaler, other medications, then administered the other inhaler. LPN #7 brought both inhalers back to the medication cart. When asked about the inhalers being on the overbed table LPN #7 stated that there was no barrier. Both inhalers were cleaned prior to putting them back into the boxes and into the medication cart. LPN #6 took one (1) inhaler into the room of Resident #133, placed it on the overbed table, gave instructions to the Resident, administered the two…

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 resident interview, observation, and staff interview, the facility failed to provide reasonable accommodation of resident needs. The cord to Resident #29's over the bed light was too short to be used when the Resident was in bed. This practice had the potential to affect a limited number of residents. Resident identifier: #29. Facility census: 33. Findings included: a) Resident #29 During an interview on 05/16/22 at 2:17 PM, Resident #29 remarked that the over-the-bed light cord was too short for him to turn it on and off while in bed. Resident #29 further stated, It would be nice not to have to go all the way over to the door to flip the switch on and off. On 05/17/22 at 10:40 AM, the Director of Nursing (DON) confirmed the cord to the over-the bed light was too short for Resident #29 to use. The DON reported she would address the concern immediately and have maintenance add an extension to it. The DON confirmed every resident room was set up in the same fashion with a shorter cord for the over-the-bed light. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence a copy of the Notice of Transfer was sent to the Ombudsman. This was true for one (1) of two (2) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #20. Facility census: 33. Findings included: a) Resident #20 An electronic medical record review was completed on 05/17/22 at 9:29 AM. Resident #20 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #20's legal representative. During an interview on 05/17/22 at 1:44 PM, the Minimal Data Set (MDS) Coordinator reported the facility was unable to produce evidence the written Notice of Transfer/Discharge was given to Resident #20's legal representative. Additionally, the facility failed to produce…

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 medical record review and staff interview, the facility failed to provide evidence a bed hold notification was given to a resident or the resident's representative before being transferred to an acute care hospital. This had the potential to affect all residents being transferred. Resident identifier: Resident #20. Facility census: 33. Findings included: a) Resident #20 An electronic medical record review was completed on 05/17/22 at 9:29 AM. Resident #20 was discharged to the hospital on [DATE]. There was no evidence a bed hold notification was provided to Resident #20's legal representative. During an interview on 05/17/22 at 1:47 PM, the Minimal Data Set (MDS) Coordinator reported the facility was unable to produce evidence the bed hold notification was provided. .

Based on record review and staff interview, the facility failed to complete a comprehensive assessment of a resident in accordance with the mandated timeframe's. An annual Minimum Data Set (MDS) was not completed in a timely fashion. This was true for one (1) of 13 residents reviewed during the annual long-term care survey process. Resident identifier: #18. Facility census: 33. Findings included: a) Resident #13 A brief medical record review was completed on 05/17/22 at 10:20 AM. An annual MDS should have been completed by 01/28/22. There was no evidence the facility had completed and submitted the MDS in accordance with the mandated timeframe's. During an interview on 05/17/22 at 1:55 PM, the MDS Coordinator confirmed the facility had failed to complete Resident #13's annual MDS in a timely fashion. It was an oversight that was caught. The annual MDS was completed and submitted on 05/02/22, which did not meet the requirement of conducting a comprehensive assessment once every 12 months. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to develop a person centered care plan with measurable goals and time frames for a resident with falls. This is true for one (1) of four (4) reviewed for falls. Facility census: 33. Findings included: a) Resident (R) #11 A review of the medical record revealed R #11 has dementia and fell on [DATE], 03/11/22 and 03/14/22. The care plan identifies these recent falls under the section titled ADL Functional / Rehabilitation Potential but lacks a measurable goal related to these incidents. During an interview on 05/17/22 at 12:30 PM, the Assistant Director of Nursing (ADON) agreed R #11's care plan lacks a person centered measurable goal related to the falls. .

Based on medical record review and staff interview, the facility failed to revise the care plan for falls after each assessment. This is true for one (1) of four (4) residents reviewed for falls. Resident identifiers: #9. Facility census: 33. Findings included: a) Resident (R) #9 Review of the medical record revealed R #9's quarterly Minimum Data Set assessment (MDS) with an Assessment Reference Date (ARD) of 04/15/22 noted R #9's fall with no major injury. The care plan identifies R #9's recent fall on 04/11/22 but lacks any intervention put in place after the recent fall. During an interview on 05/17/22 at 2:24 PM, the Assistant Director of Nursing (ADON) reported the care plans are not updated after every fall. .

Based on medical record review and staff interview, the facility failed to develop and implement comprehensive person-centered care plans with measurable goals and interventions for residents with dementia. Care plans were not developed for residents with anxiety and depression to assist the residents in attaining or maintaining their highest practicable quality of life. This is true for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #11 and #9. Facility census: 33. Findings included: a) Resident (R) #11 A review of the medical record revealed R #11 has non-Alzheimer's dementia, depression and anxiety. The care plan notes the use of psychotropic drugs and the risk for post-trauma syndrome related to placement in a long term care setting and falls. Complicated by the inability to self care, depression, anxiety and the death of a spouse. The goal was for R #11 to receive the lowest possible dosage of the prescribed medication. The interventions listed are related to the administration and monitoring of the prescribed medication, education of…

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 and staff interview, the facility failed to store food in accordance with professional standards for food safety. This practice had the potential to affect a limited number of residents currently residing in the facility. Facility census: 33. Findings included: a) Tour of Kitchen During a tour of the kitchen on, 05/16/22 at 10:40 AM, Retail Manager of the Health Ways Cafe confirmed there were two (2) five pound bags of frozen chicken opened and stored in the freezer but neither bag was labeled or dated. He also confirmed facility protocol mandates labeling and dating all food items in use. b) Tour of Kitchenette on Long Term Care Unit During a tour of the Long Term Care Unit kitchenette, on 05/16/22 at 10:55 AM with the Retail Manager of the Healthy Ways Cafe confirmed there was a bag of 'Nilla Wafers opened but not labeled or dated. He also confirmed facility protocol mandates labeling and dating all food items in use. .

Based on record review and staff interview, the facility failed to maintain a medical record that was complete, accurately documented, readily accessible and systematically organized. The facility failed to obtain and document a physician order for code status once a resident expressed their cardiopulmonary resuscitation choice. This was true for two (2) of 13 resident records reviewed during the annual long-term care survey process. Resident identifiers: #30 and #133. Facility census: 33. Findings included: a) Resident #30 A brief Electronic Medical Record (EMR) review, on 05/16/22 at 3:13 PM, found Resident #30 had a Physician Orders for Scope of Treatment (POST) form on file which outlined Resident #30's cardiopulmonary resuscitation orders as: Do Not Attempt Resuscitation. Further review of the EMR found the top of Resident #30's record read, Resus [resuscitation] Status Not Ordered. During an interview on 05/17/22 at 12:40 PM, the Director of Nursing (DON) explained the Resus Status Not Ordered meant that an official physician's order had not yet been entered under active…

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.