South Roanoke Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at South Roanoke Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 24, 2025

  Based on observation, staff interviews, and facility document review, the facility staff failed to adequately prevent hair from contacting food in the facility kitchen. The findings were: Facility staff failed to consistently wear a beard net while preparing food in the kitchen. On 04/22/25 at 4:15 p.m. the surveyor returned to the kitchen for observations while staff prepared residents' food trays. One cook (Food Service Aide - Other Employee #2) with visible facial hair was observed without a net over the facial hair. The acting director of food and nutrition was present and when asked, reported the food service aide should have their facial hair covered. The director instructed Other Employee #2 to apply a beard net. […]

• No harm, potential for more than minimal, widespreadF922Apr 24, 2025

  Based 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. The findings include: The facility staff failed to have a written procedure to: (a) address the facility's water needs if the facility experiences a loss in the normal water supply and (b) detail the process to ensure water availability if the facility experiences a loss in the normal water supply. The surveyor reviewed the facility's process/procedure to ensure water availability in response to the loss of normal water supply; this was reviewed as part of the facility's emergency preparedness program. […]

• No harm, potential for more than minimal, widespreadF812Mar 24, 2022

  Based 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. The findings include: The initial tour of the kitchen/food service area was conducted on 3/22/22 at 9:53 a.m. Two (2) dietary staff members (SM) #26 and SM #27 participated in the tour. The following was observed: An open bag diced potatoes were observed in the reach-in freezer. The diced potatoes were uncovered. A bag of chicken flavored tofu was in contact with the diced potatoes. The refrigerator contained three (3) cups of orange juice and four (4) cups of grape juice that had been poured from a container into individual cups. […]

• No harm, potential for more than minimal, widespreadF865Mar 24, 2022

  Based on staff interview and facility document review, the facility staff failed to provide a quality assurance and performance improvement (QAPI) plan for the facility. The findings were: The administrative team provided a policy titled, Quality Assurance and Performance Improvement; however, no evidence related to the development, implementation, or evaluation of corrective actions or performance improvement activities was provided. The Regional Director of Clinical Services (RDCS) and the facility's Administrator were interviewed on 03/24/2022 at 2:13 p.m. about the facility's QAPI plan. The RDCS said that although the current administrative team had searched everywhere, they were not able to provide any documentation to evidence their QAPI plan. […]

• No harm, potential for more than minimal, widespreadF867Mar 24, 2022

  Based 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. The findings were: On 03/24/2022 at 2:13 p.m.,during review of the facility Quality Assessment and Perfomance Improvement Prgram, the Regional Director of Clinical Services (RDCS) and the facility's Administrator were interviewed. The RDCS said that although the current administrative team had searched everywhere, they were not able to provide any documentation to evidence their QAPI plans of action for quality deficiencies. No further information was provided prior to the exit conference.