Roane General Hospital

In the surveyor’s words

From the most serious findings on record at Roane General Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF756May 18, 2022

  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. […]

• No harm, potential for more than minimal, patternF585Sep 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF636Sep 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF756Sep 25, 2025

  Based 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. Findings included: a) Resident #3 A record review for Resident #3 revealed a pharmacy recommendation dated 04/18/25. The recommendation stated the resident was due for a gradual dose reduction (GDR) assessment for Bupropion which was received for a diagnosis of Depression and Escitalopram also for a diagnosis of Depression. […]

• No harm, potential for more than minimal, patternF880Sep 25, 2025

  Based 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. […]