ROANE GENERAL HOSPITAL

200 HOSPITAL DRIVE, SPENCER, WV 25276 (304) 927-4444
Non profit - Other 35 Beds Independent Data: November 2025
Trust Grade
80/100
#6 of 122 in WV
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Last Inspection: December 2023

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Roane General Hospital in Spencer, West Virginia has earned a Trust Grade of B+, which means it is above average and recommended for families seeking care. It ranks #6 out of 122 facilities in the state, placing it in the top half, and is the best option among the two nursing homes in Roane County. The facility is improving, with a significant drop in issues from 11 in 2023 to just 2 in 2025. Staffing is a relative strength, with a 4/5 star rating and a turnover rate of 40%, which is lower than the state average. However, the facility has concerning RN coverage, being below 96% of West Virginia facilities, which could impact care quality. While there have been no fines, the inspector's findings highlighted several areas of concern, such as a failure to maintain proper medication review policies, cleanliness issues in the kitchen, and staff not performing hand hygiene when serving meals, which raises infection risk. Overall, Roane General Hospital has strengths in staffing and overall quality, but families should be aware of the identified weaknesses and the need for improvements in specific care practices.

Trust Score
B+
80/100
In West Virginia
#6/122
Top 4%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
11 → 2 violations
Staff Stability
○ Average
40% turnover. Near West Virginia's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most West Virginia facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
29 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★★
5.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 11 issues
2025: 2 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (40%)

    8 points below West Virginia average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Staff Turnover: 40%

Near West Virginia avg (46%)

Typical for the industry

The Ugly 29 deficiencies on record

Sept 2025 2 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within ...

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Based on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time frame. This was a random opportunity for discovery. Resident identifier: #21. Facility census: 32. Findings include:a) Resident 21During a Facility Reported Incident investigation for Resident #21 found a complaint/concern on 04/26/25. The complaint/concern stated, Resident #21 assisted to the wheelchair without the physician ordered Hoyer lift.Subsequent review of the medical record revealed the complaint/concern on 04/26/25 for Resident #21 was investigated but not reported to the appropriate services within the allotted time limits During an interview with DON on 09/24/25 at 3:30 PM she verified the complaint/concern on 04/26/25 for Resident #21 was not reported timely. She stated the incident happened over a weekend and did not get reported. She stated that concerns and grievances about neglect in Resident care should be reported to the appropriate services, Adult Protective services (APS), Office of Health Facility Licensure & Certification (OHFLAC) and State or regional Long-Term Care Ombudsman within 24 hours.
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to conduct a thorough investigation into a Facility Reported Incident (FRI) as required. Additionally, the facility failed to interview and as...

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Based on interview and record review, the facility failed to conduct a thorough investigation into a Facility Reported Incident (FRI) as required. Additionally, the facility failed to interview and assess all dependent residents to confirm that they had not suffered any harm or injury. Resident Identifier #38. Facility Census: 32. Findings include: a) Resident #38During an investigation of a Facility Reported Incident (FRI) on 09/24/25, at approximately 1:13 PM, it was discovered that on June 16, 2024, at 9:17 PM, Licensed Practical Nurse (LPN) #25 reported that Resident #38 had visible bruising on the left underarm and left upper arm.Review of the facility investigation on 09/24/25 at approximately 10:30 AM revealed the following documents and statements:Investigative document by Director of Nursing (DON) on 06/17/25 [Typed as Written] Bruise - Purple in color, appears new, no fading noted to edges or center of bruise.Bruise is located at the mid-clavicular left chest and extends to the proximal upper left arm and distally towards the elbow. ROM is normal for resident. Physician notified and no new orders.Skin assessment on last shower day reports no bruising and only refers to the resident's skin tear to the right forearm, which is healing well.Staff Interviews for Caregivers Working 6/14/24 - 6/16/24.06/17/24: Spoke with Nursing Assistant (NA) #153, who was the caregiver for [Resident] on 6/14 7a-3p shift, and she denies that there were any bruised areas during this time. She reports that she did change [Resident's] top and no skin alterations were noted.i06/17/24: Spoke with NA #151 caregiver for [Resident] on 6/13/24 3p-11p shift and she does not recall a bruised area. Stated that all she recalls is the skin tear area to her right arm. 06/18/24: Spoke with NA #152, caregiver for [Resident] on 6/15/24 and 06/16/24, she denies seeing bruising to DW on these days during personal care.NA #151 reports that CNA students were on unit Sunday 6/16/24 and performed multiple transfers without employee assistance.[Resident's] roommate is incapacitated and unable to provide any insight to injury.At this time, it is inconclusive as to who or how bruising was caused/occurred to [Resident]. After multiple staff interviews it was discovered that there are multiple reports of improper transfer techniques. [Resident] should always transferred utilizing a full body lift. Staff report that it is easier to transfer her by pivoting from chair to bed or bed to chair.Discussed with staff safety and injury concerns with transfer practices and will initiate mandatory competency regarding transfers, lift use, hand off report regarding transfer orders and where to locate transfer order directions in the electronic medical record.A memo sent by DON to all staff dated 06/17/25 at 3:22 PM, which stated [Typed as Written]: Good afternoon, it has come to my attention that some staff are electing not to use the appropriate care planned or ordered transfer devices for residents. This is not an option. Transfer/lift status is determined by staff input as well as therapy evaluation for resident safety utilizing the least restrictive device that maintains resident functionality and safety of the resident as well as the staff. Lifts are to be utilized for residents as ordered in their care plan. If a lift is not being used and is ordered this is grounds for neglect/abuse especially if/when it results in resident injury. I will be scheduling mandatory competencies and evaluations on lift use as well as determining where to find the resident lift orders/status. Please feel free to see me if you have any questions or concerns regarding this policy.Another memo from the DON to staff dated 07/16/24 (approximately a month later) at 2:51 PM, which stated [Typed as Written]: Lift competencies will be held tomorrow, 07/17/25, and Thursday, 07/18/25. You will be required to operate the lift with supervision from physical therapy or the DON as well as verbalize where to find information regarding resident lift status. Competency evaluations will be for full body and sit to stand lifts. I realize not everyone will be able to make a session tomorrow. I will be scheduling a make-up time as well.Wednesday 07/17/2410:30, 10:45, 11:00, 11:15Thursday 07/18/2413:00, 13:15, 13:30, 13:45, 15:30.Record review on 09/24/25 at 12:11 PM revealed in-service information and a sign-in sheet that documented staff in-services as having been completed.Further review of records on 09/24/25, at approximately 2:00 PM, revealed that the incident had been reported to the Director of Nursing (DON) on 06/16/24, at 9:58 PM. The Initial Report was submitted and received by the Office of Health Facility Licensure and Certification (OHFLAC) on 06/17/24 at 12:29 PM by SW #150.The five-day follow up submitted to OHFLAC on 06/20/24 at 10:54 AM, by Social Worker #150, and the result of the investigation was noted to be inconclusive.However, the facility stated that the DON would be implementing mandatory competencies regarding transfers, lift use, hand-off reports regarding transfer orders, and where to locate transfer order directions in the electronic medical record.Further investigation on 09/24/25 at 2:45 PM revealed that:NA #151 and #152 were no longer employed at the facility. SW #150 was also no longer at the facility.LPN #25 worked the night shift and was unavailable for interview, and NA #153 (now an RN) worked night shifts at the hospital and was also unavailable for interview. During an interview with the DON on 09/24/25 at approximately 3:00 PM, the DON was asked about the investigation, and confirmed that while staff members had been questioned about the care of Resident #38, no other dependent residents had been interviewed or assessed for injury soon after the incident was reported.
Dec 2023 11 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation and staff interview the facility failed to ensure a dignified dining experience for two (2) residents. Two (2) residents were not served their meal at the same time as the other r...

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Based on observation and staff interview the facility failed to ensure a dignified dining experience for two (2) residents. Two (2) residents were not served their meal at the same time as the other residents sitting at their table. Resident identifiers: #19, and #25. Facility census: 35. Findings included: a) Resident #19 During an observation on 12/04/23 at 12:45PM Resident # 19 was seated at the table that was served third in the dining room. Four (4) other residents were seated at the same table. Two (2) of the residents were given their lunch tray at 12:45PM, then the next table was served. Resident #19 did not get his tray until 1:00PM During an Interview, on 12/04/23 at 12:47PM, Nursing Assistant (NA) #65, She stated, We usually do serve the trays in order, but some days they get mixed up. They are mixed up today. During an interview on 12/04/23 at 12:50PM with staff member Licensed Practical Nurse (LPN) # 39, she stated, They are not in order today. I'm not sure why. A review 12/04/23 at 2:00PM of the facilities Meal Service policy reads under procedure number 8 {Nursing staff will arrange meal tickets in an order to enable serving all residents at any given table at the same time.} b) Resident # 25 During an observation, on 12/04/23 at 12:45PM, Resident #25 was seated at the table that was served third in the dining room. Four (4) other residents were seated at the same table. Two (2) of the residents were given their lunch tray at 12:45PM, then the next table was served. Resident #25 did not get his tray until 1:00 PM During an Interview, on 12/04/23 at 12:47PM, Nursing Assistant (NA) #65, stated, We usually do serve the trays in order, but some days they get mixed up. They are mixed up today. During an interview, on 12/04/23 at 12:50PM, with Licensed Practical Nurse (LPN) # 39, she stated, They are not in order today. I'm not sure why. A review of the facilities Meal Service policy revealed under procedure number 8 Nursing staff will arrange meal tickets in an order to enable serving all residents at any given table at the same time.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Based on observation and staff interview, the facility failed to ensure residents had reasonable accommodation of needs by not providing access for the residents to turn over bed lights on and off on ...

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Based on observation and staff interview, the facility failed to ensure residents had reasonable accommodation of needs by not providing access for the residents to turn over bed lights on and off on own. This failed practice was found to be true for four (4) of six (6) residents. Resident identifiers: #12, #6, #13, and #236. Facility census 35. Findings included: a) Resident #12 During an observation on 12/04/23 at 1:15 PM of Resident #12's room revealed that Resident #12's room was not arranged in a fashion in which Resident #12 could turn on/off their own over the bed light. During an interview, on 12/05/23 at 1:57 PM, with Nurse Aide (NA) #27 the NA stated, The residents with the long strings usually ask for them. The others just ring their call bell and we turn it on and off for them. Resident #12 uses the call light so they should be able to turn the light on and off. During a record review on 12/05/23 at 3:00 PM of Resident #12's care plan revised on 08/02/23 has not mention of Resident #12 not being able to turn on the bed light themselves. b) Resident #6 An observation on 12/04/23 at 1:20 PM of Resident #6's room revealed Resident #6's room was not arranged in a fashion in which Resident #6 could turn on/off on their own over the bed light. During an interview on 12/05/23 at 1:57 PM with NA #27 stated, The residents with the long strings usually ask for them. The others just ring their call bell, and we turn it on and off for them. Resident #6 uses the call light so they should be able to turn the light on and off. During a record review on 12/05/23 at 3:00 PM of Resident #6's care plan revised on 08/16/23 has no mention of resident #6 not being able to turn on the light themselves. c) Resident #13 During an observation on 12/04/23 at 1:30 PM of Resident #13's room revealed that Resident #13's room was not arranged in a fashion in which resident #13 could turn on/off their own over the bed light. During an interview on 12/05/23 at 1:57 PM with NA #27 stated, The residents with the long strings usually ask for them. The others just ring their call bell, and we turn it on and off for them. During a record review on 12/05/23 at 3:00 PM of Resident #13's care plan reviewed on 09/13/23 has not mention of resident #13 not being able to turn on the bed light themselves. d) Resident #236 An observation, on 12/04/23 at 1:30 PM, of Resident #236's room revealed that Resident #236's room was not arranged in a fashion in which resident #236 could turn on/off their own over the bed light. During an interview on 12/05/23 at 1:57 PM with NA #27 stated, The residents with the long strings usually ask for them. The others just ring their call bell, and we turn it on and off for them. During a record review on 12/05/23 at 3:00 PM of Resident #236's care plan reviewed on 09/13/23 has not mention of Resident #236 not being able to turn on the bed light themselves.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Based on observation, resident interview and staff interview the facility failed to establish a grievance policy which included the required information. The facility's grievance policy failed to incl...

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Based on observation, resident interview and staff interview the facility failed to establish a grievance policy which included the required information. The facility's grievance policy failed to include the contact information of the grievance official with whom a grievance can be filed. This was a random opportunity for discovery. Facility census: 35. Finding included: a) Resident Council During a meeting with the facilities Resident Council on 12/05/23 at 11:00 AM the resident group indicated they are not sure who to file a grievance with and they just tell whoever will listen. During a review on 12/05/23 at 2:00 PM of the facilities Resident Complaint policy there was no name or contact information for the person they would file a grievance with. During an interview, on 12/06/23 at 9:30 AM, with Director of Nursing (DON) the DON stated, The social workers office is upstairs. If a resident has a complaint, we put the form in her box for her to pick up. The DON confirmed the social workers contact information was not on the policy. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to initiate a significant change Minimum Data Set (MDS...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to initiate a significant change Minimum Data Set (MDS) when a resident was ordered Hospice services and had less than six (6)months to live. This was true for one (1) of two (2) residents reviewed for Hospice. Resident identifier: #35. Facility census: 35. Findings included: a) Resident #35 On [DATE] at 10:07 AM a medical record review found Resident #35 had a change in condition when the resident experienced a major Cerebral Vascular Accident (CVA). This resident was placed on Hospice services on [DATE]. A review of the Minimum Data Set (MDS) found Death in Facility tracking was completed on [DATE]. A significant change in condition MDS was not completed when the resident was placed on Hospice. Resident #35 died on [DATE]. During an interview with the MDS Coordinator on [DATE] at 10:45 AM the coordinator stated that it was too late to do a significant change MDS because of the short time span between returning to facility and date of death . According to the Resident Assessment Instrument (RAI) manual a Significant Change in Status MDS is required when a resident enrolls in a hospice program. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure care plans were resident centered and comple...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure care plans were resident centered and complete. Resident #35's care plan was not updated to reflect hospice services. Resident #10's care plan did not include the name of the hospice and contact information for the hospice agency. Resident #16's care plan had not been updated to reflect a change in the need to contact the physician for blood glucose levels. Resident #18's care plan did not include the pressure ulcer the resident had. Resident identifiers: #35, #16, #18, #10. Facility census: 35. a) Resident #35 On [DATE] at 1:11 PM a review of the medical record found no evidence of a care plan for hospice. The facility care plan was not updated to reflect the resident was ordered hospice services. The Hospice organization assessments and care plans of 40 plus pages had to be faxed over to the nursing facility. The NHA stated that the documents were scanned into the electronic medical record. The hospice service was started on [DATE]. Resident #35 died on [DATE]. b) Resident #16 On [DATE] at 10:29 AM, a medical record was completed. There was a physician order, dated [DATE], Levemir 22 units SC (subcutaneous) 2100 (9:00 PM) for Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar.) Resident #16's Care Plan, with a review date of [DATE], instructed: Monitor blood glucose on Monday and Thursday mornings. Monitor for signs of hyperglycemia (blood glucose >151 milligram (mg) per deciliter (dl) Monitor for signs of hypoglycemia (blood glucose <60 mg/dl) Notify PCP (Primary Care Physician) on hypo/hyper blood glucose levels per physician order. Further review of the medical record revealed the following times Resident #16's blood sugar was greater than 151 mg/dl: -Monday, [DATE] at 8:00 AM, resident's blood sugar was 173 -Thursday, [DATE] at 8:00 AM, resident's blood sugar was 203 -Thursday, [DATE] at 7:44 AM, resident's blood sugar was 157 -Monday, [DATE] at 7:09 AM, resident's blood sugar was 179 -Monday, [DATE] at 7:25 AM, resident's blood sugar was 251 -Monday, [DATE] at 7:36 AM, resident's blood sugar was 157 During an interview on [DATE] at 11:42 AM, the MDS Coordinator stated the care plan directive, Notify PCP (Primary Care Physician) on hypo/hyper blood glucose levels per physician order was part of Resident #16's care plan in error. The MDS Coordinator stated Resident #16 was on a long-acting insulin and there was never any physician order that gave parameters of when to notify the physician regarding blood sugar levels. She went on to say that it had been an error that she did not remove the blood sugar parameters from Resident #16's care plan since the template for diabetes mellitus automatically includes them. c) Resident #18 During a record review on [DATE] at 11:00 AM of Resident #18's diagnosis, it revealed Resident #18 had a Pressure Ulcer (PU) to the right heel. During a record review on [DATE] at 11:10 AM of Resident #18's orders shows Resident #18 was ordered treatment for his right heel on [DATE]. During a record review on [DATE] at 11:30 AM of Resident #18's care plan there is no mention of skin issues, PU, or treatments for PU. During an interview, [DATE] at 1:38 PM, with the MDS nurse she stated, This may not be his full care plan, let me go look and I will get back to you. She then brought me a one-page care plan that had every intervention for a PU created with today's date of [DATE]. During an interview on [DATE] at 1:42 PM [NAME] President (VP) of Nursing stated, Yes it does state that it was added today, let me check on this and get back to you. During an interview on [DATE] at 2:52 PM with the VP of Nursing, she stated, She had to add some interventions, that's why it was dated for today. She also stated she had not updated it yet. d) Resident #10 During a medical record review, on [DATE], it was discovered the care plan was not developed to indicate the hospice service agency or their contact information. In an interview with the Director of Nursing (DON) on [DATE] at 12:45 PM, the DON verified the care plan for Resident #10 did not include the name of the hospice agency or their contact information.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record review, policy review and staff interview, the facility failed to follow the procedure for neurological checks for an unwitnessed fall. This was true for one (1) of two (2) falls revie...

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Based on record review, policy review and staff interview, the facility failed to follow the procedure for neurological checks for an unwitnessed fall. This was true for one (1) of two (2) falls reviewed. Resident identifier: #25. Facility census: 35. Findings included: a) Resident #25 On 12/04/23 at 3:10 PM record review shows Resident #25 had an unwitnessed fall on 11/21/23 and there were no neurological checks performed after the fall. According to facility Policy for Charting Guidelines - Falls: When a fall occurs, it is necessary to assess the resident and begin documentation per the Falls guidelines to reduce the chance that an undetectable injury may be present. It states the process as follows: Neuro checks initially and EVERY 4 HOURS for 24 hours. This was confirmed with the Registered Nurse (RN), [NAME] President of Nursing #32 on 12/05/23 at 12:38 PM when she stated staff should have completed neurological checks for 24 hours after the fall occurred.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

. Based on observation and staff interview, the facility failed to ensure all drugs were labeled in accordance with currently accepted professional principles. It was discovered in the medication stor...

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. Based on observation and staff interview, the facility failed to ensure all drugs were labeled in accordance with currently accepted professional principles. It was discovered in the medication storage refrigerator that a box of insulin for Resident #8 had not been labeled with the resident's name. This failed practice had the potential to affect any resident receiving medication from the medication storage refrigerator. Resident identifier: #8. Facility census: 35. Findings included: a) Medication storage refrigerator During an observation, on 12/06/23 at 9:00 AM, of the medication storage refrigerator. It was discovered the box containing the Humulin R vial was not labeled with Resident #8's name. In an interview on 12/06/23 at 9:05 AM with the Minimum Data Set (MDS) Coordinator, verified the box of Humulin R had not been labeled with Resident #8's name. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. This was true for one (1) of 16 residents who had physician orders reviewed du...

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Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. This was true for one (1) of 16 residents who had physician orders reviewed during the Long-Term Care Survey Process. There were incomplete physician's orders for hospice services. The orders did not include the name of the contracted hospice service provider or their contact information for Resident #10. Resident identifier: #10. Facility census: 35. Findings included: a) Resident #10 During a medical record review, on 12/05/23, it was noted the orders for hospice services did not include a service agency or any contact information. In an interview with the Director of Nursing (DON) on 12/05/23 at 12:40 PM, verified the orders for hospice services were incomplete. The orders did not include the agency providing the hospice services or the contact information. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

. Based on observation and staff interview, the facility failed to maintain a wheelchair in good working order. This was a random opportunity for discovery. Resident identifier: #15. Facility census: ...

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. Based on observation and staff interview, the facility failed to maintain a wheelchair in good working order. This was a random opportunity for discovery. Resident identifier: #15. Facility census: 35. Findings included: a) Resident #15 On 12/05/23 8:50 AM an observation of the wheelchair handles revealed they were covered with pink tape. The tape had multiple tears and shredded pieces. The ends of the brakes were open. The brake handles could not be cleaned and had the potential for injury. During an observation with the Director of Nursing (DON) at this same time the DON agreed the brake handle needed new covers. These were replaced on 12/05/23.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

. Based on observation and staff interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. It was discovered during...

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. Based on observation and staff interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. It was discovered during the kitchen tour that a stand-alone warming unit was dirty. The deficient practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 35. Findings included: a) Kitchen tour During the kitchen tour, on 12/04/23 at 12:15 PM, an observation revealed a warming unit needed to be cleaned. Crusted food particles were on the ledge of the door opening. In an interview and observation on 12/04/23 at 12:25 PM, the Certified Dietary Manager (CDM) verified the warming unit needed cleaned. .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, policy review and staff interview, the facility failed to provide hand hygiene to prevent the development and transmission of communicable diseases and infections. This was a ran...

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Based on observation, policy review and staff interview, the facility failed to provide hand hygiene to prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident Identifiers: #6, #19, #27, #30. Facility Census: 35 Findings included: a) On 12/04/23 at 12:20 PM it was observed that staff was passing the lunch meal trays in the dining room without providing hand hygiene for the Residents #6, #19, #27 and #30. On 12/04/23 at 12:38 PM this was confirmed by Nurse Aide (NA) #27 who stated they usually pass warm, wet wash cloths to residents to perform their own hand hygiene. She further stated that she did not know why they did not pass them on this day. At this time, the Registered Nurse (RN), [NAME] President of Nursing #32 came into the dining room and the finding was confirmed with her as well and she instructed staff to pass the washcloths. b) Hand hygiene during medication pass During a random opportunity for discovery, on 12/05/23 at 8:45 PM, Licensed Practical Nurse (LPN) #39 dropped a container of applesauce on the floor during the medication pass. She proceeded to clean up the applesauce with a paper towel. The paper towel used to clean up the applesauce was discarded in the trash can on the medication cart. There was no evidence LPN #39 performed any hand hygiene before preparing to administer the next medication. In an interview with LPN #39 on 12/06/23 at 8:47 AM, was asked if she had performed proper hygiene after cleaning up the applesauce from the floor. She reported she had not performed proper hand hygiene before administering the next medication. .
May 2022 13 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

. Based on resident interview, observation, and staff interview, the facility failed to provide reasonable accommodation of resident needs. The cord to Resident #29's over the bed light was too short ...

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. Based on resident interview, observation, and staff interview, the facility failed to provide reasonable accommodation of resident needs. The cord to Resident #29's over the bed light was too short to be used when the Resident was in bed. This practice had the potential to affect a limited number of residents. Resident identifier: #29. Facility census: 33. Findings included: a) Resident #29 During an interview on 05/16/22 at 2:17 PM, Resident #29 remarked that the over-the-bed light cord was too short for him to turn it on and off while in bed. Resident #29 further stated, It would be nice not to have to go all the way over to the door to flip the switch on and off. On 05/17/22 at 10:40 AM, the Director of Nursing (DON) confirmed the cord to the over-the bed light was too short for Resident #29 to use. The DON reported she would address the concern immediately and have maintenance add an extension to it. The DON confirmed every resident room was set up in the same fashion with a shorter cord for the over-the-bed light. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representati...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence a copy of the Notice of Transfer was sent to the Ombudsman. This was true for one (1) of two (2) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #20. Facility census: 33. Findings included: a) Resident #20 An electronic medical record review was completed on 05/17/22 at 9:29 AM. Resident #20 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #20's legal representative. During an interview on 05/17/22 at 1:44 PM, the Minimal Data Set (MDS) Coordinator reported the facility was unable to produce evidence the written Notice of Transfer/Discharge was given to Resident #20's legal representative. Additionally, the facility failed to produce evidence a copy of the Notice of Transfer/Discharge was sent to the Ombudsman. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a bed hold notification was given ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide evidence a bed hold notification was given to a resident or the resident's representative before being transferred to an acute care hospital. This had the potential to affect all residents being transferred. Resident identifier: Resident #20. Facility census: 33. Findings included: a) Resident #20 An electronic medical record review was completed on 05/17/22 at 9:29 AM. Resident #20 was discharged to the hospital on [DATE]. There was no evidence a bed hold notification was provided to Resident #20's legal representative. During an interview on 05/17/22 at 1:47 PM, the Minimal Data Set (MDS) Coordinator reported the facility was unable to produce evidence the bed hold notification was provided. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

. Based on record review and staff interview, the facility failed to complete a comprehensive assessment of a resident in accordance with the mandated timeframe's. An annual Minimum Data Set (MDS) was...

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. Based on record review and staff interview, the facility failed to complete a comprehensive assessment of a resident in accordance with the mandated timeframe's. An annual Minimum Data Set (MDS) was not completed in a timely fashion. This was true for one (1) of 13 residents reviewed during the annual long-term care survey process. Resident identifier: #18. Facility census: 33. Findings included: a) Resident #13 A brief medical record review was completed on 05/17/22 at 10:20 AM. An annual MDS should have been completed by 01/28/22. There was no evidence the facility had completed and submitted the MDS in accordance with the mandated timeframe's. During an interview on 05/17/22 at 1:55 PM, the MDS Coordinator confirmed the facility had failed to complete Resident #13's annual MDS in a timely fashion. It was an oversight that was caught. The annual MDS was completed and submitted on 05/02/22, which did not meet the requirement of conducting a comprehensive assessment once every 12 months. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to develop a person centered care plan with measurable...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to develop a person centered care plan with measurable goals and time frames for a resident with falls. This is true for one (1) of four (4) reviewed for falls. Facility census: 33. Findings included: a) Resident (R) #11 A review of the medical record revealed R #11 has dementia and fell on [DATE], 03/11/22 and 03/14/22. The care plan identifies these recent falls under the section titled ADL Functional / Rehabilitation Potential but lacks a measurable goal related to these incidents. During an interview on 05/17/22 at 12:30 PM, the Assistant Director of Nursing (ADON) agreed R #11's care plan lacks a person centered measurable goal related to the falls. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

. Based on medical record review and staff interview, the facility failed to revise the care plan for falls after each assessment. This is true for one (1) of four (4) residents reviewed for falls. Re...

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. Based on medical record review and staff interview, the facility failed to revise the care plan for falls after each assessment. This is true for one (1) of four (4) residents reviewed for falls. Resident identifiers: #9. Facility census: 33. Findings included: a) Resident (R) #9 Review of the medical record revealed R #9's quarterly Minimum Data Set assessment (MDS) with an Assessment Reference Date (ARD) of 04/15/22 noted R #9's fall with no major injury. The care plan identifies R #9's recent fall on 04/11/22 but lacks any intervention put in place after the recent fall. During an interview on 05/17/22 at 2:24 PM, the Assistant Director of Nursing (ADON) reported the care plans are not updated after every fall. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

. Based on medical record review and staff interview, the facility failed to develop and implement comprehensive person-centered care plans with measurable goals and interventions for residents with d...

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. Based on medical record review and staff interview, the facility failed to develop and implement comprehensive person-centered care plans with measurable goals and interventions for residents with dementia. Care plans were not developed for residents with anxiety and depression to assist the residents in attaining or maintaining their highest practicable quality of life. This is true for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #11 and #9. Facility census: 33. Findings included: a) Resident (R) #11 A review of the medical record revealed R #11 has non-Alzheimer's dementia, depression and anxiety. The care plan notes the use of psychotropic drugs and the risk for post-trauma syndrome related to placement in a long term care setting and falls. Complicated by the inability to self care, depression, anxiety and the death of a spouse. The goal was for R #11 to receive the lowest possible dosage of the prescribed medication. The interventions listed are related to the administration and monitoring of the prescribed medication, education of the resident and family, developing a trusting relationship and encouraging visitors. The care plan lacks person centered non-pharmacological interventions to assist R #11 in dealing with depression and anxiety. The Assistant Director of Nursing (ADON) reviewed R #11's care plan on 05/17/22 at 12:30 PM, and confirmed the care plan lacks resident specific goals and interventions for the diagnoses of depression and anxiety. b) Resident (R) #9 Review of the medical record revealed R #9 has a diagnosis of dementia with anxiety. The care plan identifies the use of psychotropic medications for major depression as evidenced by social withdrawal, restlessness and tearfulness. The goal is to receive the lowest effective dose of the medication. The interventions are to educate on the risk and benefits, evaluate for a dose reduction, monitor targeted behaviors for effectiveness of the drug, and observe for side effects of the medication. The care plan lacks person centered non-pharmacological interventions to assist R #9 in dealing with anxiety. During an interview on 05/17/22 at 1:48 PM, the Director of Nursing (DON) confirmed R #9's care plan lacks non-pharmacological interventions to assist in with dealing with anxiety. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

. Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food safety. This practice had the potential to affect a limited number of r...

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. Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food safety. This practice had the potential to affect a limited number of residents currently residing in the facility. Facility census: 33. Findings included: a) Tour of Kitchen During a tour of the kitchen on, 05/16/22 at 10:40 AM, Retail Manager of the Health Ways Cafe confirmed there were two (2) five pound bags of frozen chicken opened and stored in the freezer but neither bag was labeled or dated. He also confirmed facility protocol mandates labeling and dating all food items in use. b) Tour of Kitchenette on Long Term Care Unit During a tour of the Long Term Care Unit kitchenette, on 05/16/22 at 10:55 AM with the Retail Manager of the Healthy Ways Cafe confirmed there was a bag of 'Nilla Wafers opened but not labeled or dated. He also confirmed facility protocol mandates labeling and dating all food items in use. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

. Based on record review and staff interview, the facility failed to maintain a medical record that was complete, accurately documented, readily accessible and systematically organized. The facility f...

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. Based on record review and staff interview, the facility failed to maintain a medical record that was complete, accurately documented, readily accessible and systematically organized. The facility failed to obtain and document a physician order for code status once a resident expressed their cardiopulmonary resuscitation choice. This was true for two (2) of 13 resident records reviewed during the annual long-term care survey process. Resident identifiers: #30 and #133. Facility census: 33. Findings included: a) Resident #30 A brief Electronic Medical Record (EMR) review, on 05/16/22 at 3:13 PM, found Resident #30 had a Physician Orders for Scope of Treatment (POST) form on file which outlined Resident #30's cardiopulmonary resuscitation orders as: Do Not Attempt Resuscitation. Further review of the EMR found the top of Resident #30's record read, Resus [resuscitation] Status Not Ordered. During an interview on 05/17/22 at 12:40 PM, the Director of Nursing (DON) explained the Resus Status Not Ordered meant that an official physician's order had not yet been entered under active orders. The DON further explained the physician sometimes puts it in as an order when a POST form is completed. If not, nursing would contact physician and obtain the order verbally so it could be entered under active orders. The DON stated that it was an oversight that the do not resuscitate order had not been obtained. b) Resident #133 A brief electronic health record review, on 05/16/22 at 1:57 PM, found Resident #133 had a POST form on file which outlined Resident #133's cardiopulmonary resuscitation orders as: Do Not Attempt Resuscitation. Further review of the electronic medical record found the top of Resident #133's record read, Resus Status Not Ordered. During an interview on 05/17/22 at 12:40 PM, the DON explained the Resus Status Not Ordered meant that an official physician's order had not yet been entered under active orders. The DON further explained the physician sometimes puts it in as an order when a POST form is completed. If not, nursing would contact physician and obtain the order verbally so it could be entered under active orders. The DON stated that it was an oversight that the do not resuscitate order had not been obtained. .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

. Based on record review and staff interview, the facility failed to ensure three (3) of 13 residents reviewed during the long-term care survey process had advance directives completed as recognized b...

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. Based on record review and staff interview, the facility failed to ensure three (3) of 13 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Residents #4, #29 and #133 had incomplete Physician Orders for Scope of Treatment (POST) forms. Resident identifiers: #4, #29, and #133. Facility Census: 33. Findings included: a) Resident #4 A brief electronic health record review was completed on 05/16/22 at 2:23 PM. A POST form was on file. In Section F of the POST form there was no phone number provided for the physician. A review of the 2021 Using the POST form Guidance for Health Care Professionals states, Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview on 05/17/22 at 12:40 PM, the Director of Nursing (DON) reported the physician's phone number should have been given and leaving it blank was an error. The DON further stated the POST form will be updated. b) Resident #29 A brief electronic health record review was completed on 05/16/22 at 2:45 PM. A POST form was on file. In Section F of the POST form there was no phone number provided for the physician. Review of the 2021 Using the POST form Guidance for Health Care Professionals states, Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview on 05/17/22 at 12:43 PM, the DON reported the physician's phone number should have been given and leaving it blank was an error. The DON further stated the POST form will be updated. c) Resident #133 A brief electronic health record review was completed on 05/16/22 at 1:57 PM. A Physician Orders for Scope of Treatment (POST) form was on file. In Section F of the POST form there was no phone number provided for the physician. Review of the 2021 Using the POST form Guidance for Health Care Professionals states, Failure to provide a contact number may result in the inability to contact the provider regarding any errors in the form completion that need to be addressed. During an interview on 05/17/22 at 12:45 PM, the DON reported the physician's phone number should have been given and leaving it blank was an error. The DON further stated the POST form will be updated. .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment....

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. room [ROOM NUMBER] had two (2) areas of bubbling paint below the television. The bottom of Resident #18's closet door was missing the wood laminate leaving the wood surface exposed. Additionally, the facility failed to keep the dining room temperature at a comfortable temperature level. These were random opportunities for discovery. Room identifiers: 117-A and 123. Resident identifiers: #3, #18, #6. #10, #12, #15, #22, #27, and #28. Facility census: 33. Findings included: a) room [ROOM NUMBER] Observation, on 05/16/22 at 11:46 AM, found two (2) areas of bubbling paint on the wall just below the television. One area was approximately the size of a softball. The other area was approximately the size of a tennis ball. During an interview, on 05/17/22 at 11:47 AM, the Director of Nursing (DON) stated, This definitely should have been addressed and repaired. I will see that it gets done. b) room [ROOM NUMBER]-A Observation on 05/16/22 at 11:31 AM, found the laminate on the bottom of the left closet door was missing and broken off leaving the wood surface exposed. The length of the exposed wood was approximately one (1) foot. During an interview, on 05/17/22 at 11:50 AM, the DON reported the missing laminate on the closet door was not homelike and needed to be repaired. c) Dining Room Temperature An observation in the Dining Room during the lunch meal, on 05/18/22 at 1:02 PM, found Residents using blankets due to the room being cold. The following eight (8) residents were wrapped in blankets: Resident #6, Resident #10, Resident #12, Resident #15, Resident #18, Resident #22, Resident #27, and Resident #28. Resident #10 stated that he was cold. The Maintenance Worker #49 took the ambient air temperature in the dining room at 05/18/22 at 1:12 PM. The temperature was found to be 67 degrees Fahrenheit (F). The DON stated, That does not meet acceptable temperature guidelines. It needs to be a minimum of 71 degrees F. We will address this immediately. .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

. Based on observation and staff interview, the facility failed to ensure resident inhalers were protected from contamination. In addition, nursing staff failed to wash turn off the water faucet with ...

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. Based on observation and staff interview, the facility failed to ensure resident inhalers were protected from contamination. In addition, nursing staff failed to wash turn off the water faucet with a dry paper towel after washing their hands and the laundry table was in disrepair and could not be cleaned. These practices had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #1 and #133. Facility census: 33. Findings included: a) Inhalers In addition, LPN #7 took two (2) inhalers into R#1's room and placed them on the over bed table. LPN #7 administered one (1) inhaler, other medications, then administered the other inhaler. LPN #7 brought both inhalers back to the medication cart. When asked about the inhalers being on the overbed table LPN #7 stated that there was no barrier. Both inhalers were cleaned prior to putting them back into the boxes and into the medication cart. LPN #6 took one (1) inhaler into the room of Resident #133, placed it on the overbed table, gave instructions to the Resident, administered the two (2) puffs, capped the inhaler and put the inhaler in her uniform pocket. LPN #6 confirmed a barrier was not used and the inhaler should not have been placed in her uniform pocket. b) Resident #1 and #133 On 05/17/22 at 1:08 PM observed Licensed Practical Nurses (LPN) #6, #7 washed their hands, turned off the water faucet with clean hands and then used paper towel to dry their hands. LPN's #6 and #7 confirmed proper procedure for hand washing was not followed and both washed their hands again. c) Laundry Room An observation of the laundry room on 05/16/22 at 12:40 PM with laundry manager (LM) #48 found the wooden laundry folding table in disrepair. All four (4) top edges of the table were wrapped in duct tape. The duct tape on one (1) side of the table was torn and shredded. The edge of the tape on the table top was folded back exposing the inner layer and sticky rubber glue components. The paint on the bottom shelf of the wooden table was chipped and peeling. LM #48 confirmed these findings and reported the table needs replaced.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected most or all residents

. 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 ...

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. 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. The Medication Regimen Review (MRR) policy lacks time frames for the different steps in the review process and does not identify the steps the pharmacist must take when identifying an irregularity that requires urgent action to protect the resident. The Assistant Director of Nursing (ADON) reviewed the MRR policy during an interview on 05/17/22 at 3:12 PM. The ADON confirmed the MRR policy lacks time frames for the different steps of the pharmacy review and does not identify the process the pharmacist must follow when the irregularity requires an urgent response from the physician. .
Feb 2021 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

. Based on observation, interview and record review, the facility failed to label multi-use vials in accordance with professional standards of practice. This failed practice was true for two (2) of si...

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. Based on observation, interview and record review, the facility failed to label multi-use vials in accordance with professional standards of practice. This failed practice was true for two (2) of six (6) multi-use vials reviewed for medication storage. Resident identifiers: #29, and #3. Facility census 29. Findings included: During an observation of the medication cart on 02/09/21 at 8:01 AM, with Licensed Practical Nurse #34, there were two (2) of six (6) multi-use vials of insulin which were not dated when opened. One (1) vial belonged to Resident #29 the medication was Levemir, the other belonged to Resident #3 the medication was Lantus. Both medications are used to treat diabetes (an illness that the body does not absorb or move the glucose in the blood into the cells of the body). LPN #34 confirmed both vials were open and not dated to indicate when they were first accessed. A review of the facility's policy titled: Safe Injection Practices, found the following, -Multiple dose vials will be labeled and discarded 28 days after use or in accordance with the expiration date printed on the medication. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

. Based on interview, observation and record review, the facility failed to ensure a resident who was returning to the facility was placed in an appropriate observation unit. The facility also failed ...

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. Based on interview, observation and record review, the facility failed to ensure a resident who was returning to the facility was placed in an appropriate observation unit. The facility also failed to ensure appropriate cohorting was completed when Resident #16 returned from the emergency room. This was a random opportunity for discovery. Resident identifiers: #16 and #29. Facility census 29. Findings included: a) Resident #16 On 02/08/21 at 11:36 AM, Nursing Aide (NA) #113 stated Resident #16 was ordered droplet precautions because she had gone to the emergency room (ER) and was now quarantined for 14 days. When asked if Resident #113's roommate (Resident #29) was also in quarantine, NA #113 stated, She is now. During an interview with Director of Nursing (DON) on 02/08/21 at 1:37 PM, she stated the staff put Resident # 16 back in her old room and should not have. She stated this is why Resident #29 also had to put on droplet precautions. The DON went on to say, the Attending Physician was notified and instructed us to not move the Residents. A review of medical records revealed Resident #16 was sent to the local ER due to a urinary tract infection on 2/02/21. Resident #29 returned to the facility the next day on 2/03/21. On 2/05/21 there was a nursing note stating the Attending Physician was notified about Resident #29 not being placed in a quarantine room when returning to the facility, but was placed back in her room with her roommate. On 02/10/21 at 3:13 PM, [NAME] President of nursing was asked about the cohorting of Resident #29 and #16. She stated, the staff did not follow the policy. Observation on 02/08/21 at 11:36 AM, revealed Resident #29 was in a room with signage on the door indicating the need for gown, gloves, and a mask to be worn in this room. NA#113 said her roommate was put in back in her room after going out to the ER. So now both residents are ordered droplet precautions. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

. Based on record review and interview, the facility failed to ensure each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated or the resident had a...

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. Based on record review and interview, the facility failed to ensure each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated or the resident had already been immunized. This failed practice was true for one (1) out of five (5) Residents reviewed for immunizations. Resident identifiers: #7. Facility census 29. Findings included: a) Resident #7 A review of Resident #7's medical records revealed the resident was not offered nor did they receive the pneumococcal 23 vaccine. On 02/10/21 at 2:13 PM, [NAME] President of Nursing (VP) confirmed the facility failed to follow through on obtaining the medical records for Resident #7 to ensure they had received the Pneumococcal vaccine. She stated, the nurse was supposed to get the medical information from another facility and failed follow through with obtaining the information. .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Grade B+ (80/100). Above average facility, better than most options in West Virginia.
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most West Virginia facilities.
  • • 40% turnover. Below West Virginia's 48% average. Good staff retention means consistent care.
Concerns
  • • 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Roane General Hospital's CMS Rating?

CMS assigns ROANE GENERAL HOSPITAL an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Roane General Hospital Staffed?

CMS rates ROANE GENERAL HOSPITAL's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Roane General Hospital?

State health inspectors documented 29 deficiencies at ROANE GENERAL HOSPITAL during 2021 to 2025. These included: 29 with potential for harm.

Who Owns and Operates Roane General Hospital?

ROANE GENERAL HOSPITAL is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 35 certified beds and approximately 31 residents (about 89% occupancy), it is a smaller facility located in SPENCER, West Virginia.

How Does Roane General Hospital Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, ROANE GENERAL HOSPITAL's overall rating (5 stars) is above the state average of 2.7, staff turnover (40%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Roane General Hospital?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Roane General Hospital Safe?

Based on CMS inspection data, ROANE GENERAL HOSPITAL has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Roane General Hospital Stick Around?

ROANE GENERAL HOSPITAL has a staff turnover rate of 40%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Roane General Hospital Ever Fined?

ROANE GENERAL HOSPITAL has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Roane General Hospital on Any Federal Watch List?

ROANE GENERAL HOSPITAL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

ROANE GENERAL HOSPITAL

200 HOSPITAL DRIVE, SPENCER, WV 25276 | (304) 927-4444

B+
Trust Grade (80/100)
5.0
CMS Rating
29
Deficiencies

Strengths

  • 4-star staffing
  • 5-star quality

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025