Roane General Hospital

Inspectors wroteBased on interview, record review reviews the facility failed to follow the grievance process making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. Resident identifiers: #23, #3, #123, #2, #101, #2, #19. Facility Census: 32 Findings Include: On 09/22/25 at 1:15 PM record review of Resident Council minutes for the last six (6) months found several complaints voiced to the Activity Director (AD) #14. According to the Director of Nursing (ADON) there have been no grievances for the year 2025. During sitting in on a current Resident Council meeting on 09/22/25 at 2:30 PM, there were complaints voiced. [...]

Inspectors wroteBased on staff interview and record review the facility failed to complete comprehensive assessment timely. This was true for two (2) of six (6) Resident reviewed during the Long-Term Survey Process. Resident Identifiers: #1 and #7. Facility Census: 32. Findings Included: a) Resident #1 On 09/23/25 during record review of Resident #1 MDS review of Quarterly Minimum Data Set (MDS) assessment dated [DATE], Completed Late: (assessment completion date) is more than 14 days after the (assessment reference date). The assessment was submitted 09/04/25. During an Interview on 09/24/25 at 1:55 PM the MDS Coordinator verified the submission date was past the 14-day assessment completion date. b) Resident #7 On 09/23/25 during record review of Resident #7 MDS review of Quarterly Minimum Data Set (MDS) assessment 08/08/25. Completed Late: [...]

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure the physician documented the actions or rational if no action taken to monthly drug regimen reviews and GDR's and the pharmacist failed identified an irregularity in a prescription written by the physician. This was true for four ( 4 ) of five (5) reviewed for unnecessary medications. Resident identifiers: #3, #4, #18, and #27. Facility census: 32.

Inspectors wroteBased on observation and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. Enhanced Barrier Precautions were not being followed, a nurse was giving medications without gloves and without a barrier and issues with the tile were found in the shower room. In addition ventilation issues were found in the soiled laundry room. Resident Identifiers: #7 and #10. Facility Census: 32 Findings Include: a) Food and drink at the nurses' station On 09/22/25 at 10:30 AM upon arrival to the Nurses station there were three (3) nurses with personal drinks at the nurses' station. There was also a Nurse eating at the station. According to the Facility Infection Control Policy there was to be no food/drink at the nurses' station.

Inspectors wroteBased on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frame. This was a random opportunity for discovery. Resident identifier: #21. Facility census: 32.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation into a Facility Reported Incident (FRI) as required. Additionally, the facility failed to interview and assess all dependent residents to confirm that they had not suffered any harm or injury. Resident Identifier #38. Facility Census: 32.

Inspectors wroteBased on record review and staff interview the facility failed to submit the correct admitting diagnosis on a Preadmission Screeing and Resident Review for one (1) of one (1) PASARRs reviewed. Resident Identifier: #4 Facility Census: #32. Findings Include:a) Resident #4On 09/23/25 at 01:15 PM a review of Residents #4's medical diagnoses found the following listed:Generalized anxiety disorder Major Depressive disorderChronic paranoid schizophreniaBipolar Review of the latest PASARR dated 05/18/21 submitted by the MDS Coordinator shows the following conditions: Schizophrenia DisorderHallucinationsDelusionalDisorientedSeriously impaired judgmentDementiaThe PASARR did not reflect Anxiety, Major Depressive Disorder, or Bipolar. The care plan had the following reflected on it: Anxiety, Major Depressive Disorder, and Schizophrenia. Dementia and Bipolar were not care planned. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement the care plan for the nutritional status regarding weights. This was a random opportunity for discovery. Resident Identifier: #1 Faility Census:

Inspectors wroteBased on record review and staff interview the facility failed to update the careplan to reflect current medications and diagnosis. This was true for five (5) of five (5) residents reviewed for unnecessary medications. Resident Identifier: #4 Facility Census: 32 Findings Include:a) Resident #4On 09/23/25 at 01:15 PM a review of Residents #4s medical diagnosis found the following listed:Generalized ansiety disorder - Major Depressive disorderChronic paranoid schizophreniaBipolar The careplan the following reflected on it: anxiety, major depressive disorder, schizophremia. Dementia or bipolar are not care planned. Resident #4 is also ordered the following medications: Xanax 05.mg three times a day for anxiety disorder, Lamotrigine (Lamictal) 100mg twice a day for schizophrenia, Citalopram 20 mg daily, Rexuit for schizophrenia, Zyprexa 5mg for schizophrenia. [...]

Inspectors wroteBased on record review and staff interview the facility failed to follow policy to notify the physician in regards to weights. This was a random opportunity for discovery. Resident Identifier: #1 Facility Census: 32 Findings Include:a) Resident #1On 09/23/25 at 9:10 AM record review shows an order for monthly weights. Review of the weights for this resident shows a weight gain of 14% on 05/10/25 and 11% on 05/14/25. According to the Director of Nursing (DON) on 09/23/25 at 1:00 PM there was no documentation the Physician was notified of Resident #1's weight gain in either instance. According to the facility policy for Long Term Care Significant Weight Change the Physician and Medical Power of Attorney (MPOA) would be notified of the significant weight change. [...]

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.