Roanoke Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Roanoke Rehabilitation & Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 20, 2023

  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 . […]

• No harm, potential for more than minimal, widespreadF576Mar 3, 2022

  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. […]

• No harm, potential for more than minimal, widespreadF812Mar 3, 2022

  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. […]

• No harm, potential for more than minimal, isolatedF638Sep 20, 2023

  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 . […]

• No harm, potential for more than minimal, isolatedF684Sep 20, 2023

  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. […]