South Roanoke Nursing and Rehabilitation

Inspectors wroteBased on observation, staff interviews, and facility document review, the facility staff failed to adequately prevent hair from contacting food in the facility kitchen.

Inspectors wroteBased on staff interviews and facility document review, the facility staff failed to develop procedures to detail the facility's process to ensure availability of water in response to a loss of the facility's normal water supply.

Inspectors wrote3. For Resident #59, the facility staff failed to accurately code the resident's PRN (as needed) pain medication and failed to code the resident's weight loss of 6.1% on a minimum data set (MDS) assessment dated [DATE]. Resident #59's diagnosis list indicated diagnoses that included but were not limited to Osteoarthritis, Alzheimer's Disease, Hypertension, Type 2 Diabetes Mellitus, Atrial Fibrillation, Chronic Kidney Disease-Stage 3, and History of Surgery on the Digestive System. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/9/25, assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. Review of Section J (Health Conditions) J0100 (Pain Management) B. [...]

Inspectors wrote4. For Resident #34 the facility staff failed to develop and implement a comprehensive person-centered care plan to address the resident's preferences for no oral suction and no oxygen as indicated on an advance directive form. Resident #34's diagnosis list indicated diagnoses that included but were not limited to Hypertension, Type 2 Diabetes Mellitus, Alzheimer's Disease, Adult Failure to Thrive, Dementia, Glaucoma, History of Falling, Anxiety Disorder, Depression, and Mood Affective Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/20/25, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A medical provider orders with a start date of 1/14/25 read in part, .DNR (Do Not Resuscitate) . [...]

Inspectors wrote3. The facility staff failed to document the details of the education provided to Resident #2's responsible party related to the decision to decline oxygen and oral suctioning as part of the end-of-life care choices documented on the resident's ADVANCED DIRECTIVES form. Resident #2's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], was signed as completed on [DATE]. Resident #2 was assessed as usually able to make self understood and as usually able to understand others. Resident #2's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact or borderline cognition. Resident #2's clinical documentation included a form titled ADVANCED DIRECTIVES dated [DATE]. This form indicated the resident was not to receive oxygen and/or oral suctioning as part of end-of-life care. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of the reason(s) for transfer and/or discharge to the resident and the resident's representative for one (1) of twenty-four (24) sampled residents, (Resident #59).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to accurately determine a significant change in the resident's physical condition using the RAI (resident assessment instrument) process for one (1) of twenty-four (24) sampled residents, (Resident #59).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide care and services to meet professional standards of care for 1 of 24 sampled residents, Resident #46.

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to perform neuro-checks and vital signs as ordered by a medical provider for one (1) of 24 residents (Resident #76).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure each resident receives the appropriate assistance and/or assistance devices to prevent accidents for 2 of 24 sampled residents (Resident #46 and Resident #38).

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide respiratory services for 1 of 23 Residents, Resident #65.

Inspectors wroteBased on observations, interviews, and document reviews, the facility staff failed to store and/or prepare food in a sanitary manor in the main kitchen and failed to ensure a clean and sanitary food service area.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide a quality assurance and performance improvement (QAPI) plan for the facility.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence they had developed and implemented appropriate plans of action to identify or correct quality deficiencies for the facility.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide evidence of quarterly quality assessment and assurance (QAA) committee meetings for the facility.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide the resident and/or their representative, a written summary of their baseline CP (care plan) for 2 of 20 residents, Residents #54 and #71.

Inspectors wroteBased on staff interview, resident interview, and clinical record review, the facility staff failed to review and revise the care plan to reflect the resident's current status for one of 20 residents, Resident #180; and and failed to invite the resident to the care plan meeting for one of 20 residents in the survey sample, Resident #54. 1. Resident #180 was admitted to the facility with diagnoses including diabetes mellitus, congestive heart failure, generalized muscle weakness, end stage chronic renal insufficiency, and thrombocytopenia. On the minimum data set (MDS) assessment with assessment reference date 11/24/2021, the resident scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. [...]

Inspectors wroteBased on observation, resident interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for a dependent resident for 1 of 20 residents, Resident #36.

Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to follow physicians orders for 3 of 20 residents in the survey sample, Residents #9, #71, and #180. For Resident #9, the facility failed to administer the full course of the antibiotic cephalexin ordered by the physician. For Resident #71, the facility failed to follow physician's orders for the administration of the medication cephalexin. For Resident #180, facility staff failed to obtain weights as ordered. 1. Resident #9 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia, history of falls, muscle weakness, chronic obstructive pulmonary disease, dependence on oxygen, and essential hypertension. Clinical record review revealed Resident #9 returned from a hospitalization with orders including: [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure a physician ordered supplement was kept under direct observation by the nursing staff until consumed by the resident for 1 of 20 residents, Resident #54.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to perform hand hygiene during a medication pass and pour onservation on 1 of 2 resident care units, Wing 2.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to determine flu and pneumonia status for 3 of 5 residents reviewed for vaccines, Resident's #8, #40, and #55. The facility staff was unable to provide evidence of consent or refusal in regards to the flu and/or pneumonia vaccines.

Inspectors wroteBased on observation, interviews, and document reviews, the facility staff failed to properly implement COVID-19 testing processes and/or procedures. The specimen collection was not obtained according to manufacturers instructions for one staff member (SM) #22; and the facility staff failed to conduct required COVID-19 testing on five separate occasions for for 1 of 2 staff members, SM #1.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide evidence of COVID-19 vaccination refusal for 1 of 5 residents, Resident #40.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to implement policies and procedures for additional infection control precautions for staff who are not fully vaccinated for COVID-19, for 3 of 5 employees, Staff Members (SM) #1, #2, and #3. The facility staff also failed to ensure a process for tracking the COVID-19 vaccination status of staff for 1 of 7 sampled employees, SM #4.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to prepare, store, and serve foods in a sanitary manner.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure an effective infection control program for 1 of 24 Residents, Resident #18 and failed to follow their infection control program/plan for use of an SBAR (situation, background, assessment, recommendation) technique.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, it was determined the facility staff failed to ensure Durable Do Not Resuscitate Order (DDNR) forms and/or the facility's advance directive processes were correctly implemented for 2 of 24 residents (Resident #336 and Resident #80).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide notification of changes for 1 of 24 Residents in the survey sample, Resident # 30.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide the receiving provider with the appropriate information to include the basis for the transfer, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advanced Directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information including a copy of the resident's discharge summary and the facility failed to document information provided to the receiving provider in the clinical record for 2 of 24 residents (Resident #34 and Resident #37).

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to provide notifications to the ombudsman and Resident's RP (responsible party) when a Resident was transferred for 2 of 24 Residents, Resident #34 and Resident #37.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide to the resident and the resident representative at the time of transfer/discharge written notice that specifies the duration of the bed-hold policy for 2 of 24 residents (Resident #34 and Resident #37).

Inspectors wroteBased on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to follow physician orders for 1 of 24 Residents, Resident #49.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure that 1 of 24 Residents in the survey sample received respiratory care consistent with professional standards of practice, Resident # 30.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure a medication was available for administration for 1 of 24 Residents, Resident #49.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure that 2 of 24 Residents in the survey sample were free of unnecessary psychotropic medications, Resident # 13 and Resident # 14.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure a narcotic medication (lorazepam/ativan) with the potential for abuse was stored in a locked permanently affixed box on 1 of 2 wings, wing 2.

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 2 of 24 Residents, Resident #22 and Resident #30.

Inspectors wroteBased on observations, resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to follow their policy and procedure regarding the Residents smoking supplies for 1 (one) of 24 Residents, Resident #38.