Deficiency found at Roanoke nursing home that was site of COVID-19 outbreak


ROANOKE, Va. (WFXR) — The Virginia Department of Health (VDH) has posted COVID-19 focus survey reports for Raleigh Court Health and Rehabilitation Center after on-site visits to the nursing home.

The center was the site of a COVID-19 outbreak last year. According to VDH, it was notified of the outbreak at Raleigh Court Health and Rehabilitation Center on Sept. 2, 2020. According to VDH data, Raleigh Court Health and Rehabilitation has experienced 115 COVID-19 cases and 16 deaths.

In September, VDH conducted two on-site COVID-19 focus surveys. The reports were publicly posted just last month when WFXR wrote to VDH requesting them. VDH informed WFXR that the delay in posting the reports was due to staffing issues and the volume of surveys being conducted.

“CMS (Centers for Medicare and Medicaid Services) required us to conduct an on-site focus infection control survey of every certified nursing home in the state by July 31st,” said Kim Beazley, director of VDH Office of Licensure and Certification.

The first COVID-19 focus survey at Raleigh Court Health and Rehabilitation Center was conducted in June 2020, and no deficiencies were found. A second survey dated Sept. 8, 2020 also found no deficiencies.

A third survey dated Sept. 21, 2020 states that the center was in “substantial compliance with 42 CFR Part 483.73, Requirement for Long-Term Care Facilities.” However, the report also notes a deficiency related to resident records was found.

The reports states, “Based on interviews and the review of documents, it was determined the facility staff failed to ensure a complete and/or accurate clinical record for seven (7) of seven (7) sampled

The report continues, “Review of sample resident’s clinical documentation failed to reveal evidence of screening/monitoring assessments prior to the residents’ testing positive for the COVID-19 virus.”

Beazley tells WFXR that when deficiencies are found, the nursing home has 45 days to correct them and ten days to submit a written plan of correction.

“So the plan has to be returned to us within ten days. However, they have up to 45 days to put those corrective actions in place,” said Beazley.

CMS uses a scale for the scope and severity of deficiencies, ranging from A (the least severe) to L (the most severe). The deficiency found at Raleigh Court in September had a scope and severity of “F”.

WFXR reached out to Chance Craft, administrator at Raleigh Court Health and Rehabilitation Center. He provided WFXR News with the following statement:

“Since the onset of the pandemic, we have had five infection control surveys with no deficiencies. However, on Nov. 6, 2020, we were alerted to an opportunity to improve our care by changing the way we documented our infection control protocols. In response, we immediately implemented a re-education program related to this new preferred process.

Our heroic caregivers have made tremendous sacrifices and accomplished much in the face of a historic health crisis, and we remain incredibly proud of their steadfast commitment to delivering the highest quality of care. They have made our elite 5-star CMS rating possible and we are incredibly thankful for their continued service and professional excellence during these challenging times.”

Chance Craft, administrator of Raleigh Court Health and Rehabilitation Center

VDH informed WFXR that there were two more on-site COVID-19 focus surveys conducted at Raleigh Court Health and Rehabilitation Center in December. Those reports have not yet been released. VDH says one report is still pending. It says the other report reflects that one deficiency was found pertaining to quality of care.

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