Deficiency Records for South Roanoke Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for South Roanoke Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-24 | 2022-05-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-24 | 2022-05-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-24 | 2022-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-24 | 2022-05-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-24 | 2022-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-05-08 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-03-24 | 2022-05-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-24 | 2022-05-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-24 | 2022-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-24 | 2022-05-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-24 | 2022-05-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-24 | 2022-05-08 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-24 | 2022-05-08 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-24 | 2022-05-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-29 | 2022-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-29 | 2022-03-31 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-07-09 | 2019-08-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-09 | 2019-08-23 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-07-09 | 2019-08-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-09 | 2019-08-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-09 | 2019-08-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-09 | 2019-08-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-09 | 2019-08-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-09 | 2019-08-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-09 | 2019-08-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-09 | 2019-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-09 | 2019-08-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-09 | 2019-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-09 | 2019-08-23 | N |
| Have policies on smoking. | Health | 2019-07-09 | 2019-08-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Establish methods for sharing information. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-09 | 2019-08-23 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-07-23 | 2019-08-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-23 | 2019-08-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-06-14 | 2018-07-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-06-14 | 2018-07-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-06-14 | 2018-07-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-06-14 | 2018-07-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-06-14 | 2018-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-14 | 2018-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-14 | 2018-07-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-15 | 2018-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-15 | 2018-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-15 | 2018-04-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-15 | 2018-04-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-15 | 2018-04-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-15 | 2018-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-15 | 2018-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-03-15 | 2018-04-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-03-15 | 2018-04-26 | N |
