Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Roubal Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with therapy recommendations for contact guard assist during ambulation fell and sustained a fractured femur when a CNA, unaware of the specific assistance level required, lost contact while attempting to position a wheelchair. The CNA was using a gait belt and walker, but did not maintain the necessary supervision as outlined in the care plan, leading to the resident's fall and injury.
Surveyors identified multiple failures in maintaining sanitary conditions in food storage and preparation areas, including debris and spills in the walk-in cooler and freezer, unclean utensils and equipment, improper sanitizer concentrations due to expired test strips, and improper air-drying of pans before storage. The Dietary Manager was often unsure about cleaning schedules and procedures, contributing to the observed deficiencies in food safety practices.
Surveyors identified failures in infection prevention and control, including improper use of Enhanced Barrier Precautions during high-contact care for two residents with indwelling devices and wounds, as well as lapses in aseptic technique during wound care. Additionally, the facility did not maintain an active water management plan to address stagnant water lines and lacked routine flushing or environmental testing to reduce the risk of waterborne pathogens.
Two residents were not provided with dignified care during personal hygiene activities, resulting in one resident being left uncovered and exposed to another resident entering through a shared bathroom. Staff failed to ensure privacy by not covering the resident or closing the bathroom door during care, and the urinary catheter drainage bag was left uncovered. The resident expressed feelings of embarrassment and helplessness due to these repeated lapses in privacy.
Two residents experienced significant discomfort due to excessive heat and persistent urine odors in their rooms. One resident, with severe cognitive impairment, was found overheated and weak, with staff and family noting the lack of temperature control and the need for a fan purchased by the family. The same resident's room had ongoing issues with urine odor and soiled linens not being promptly changed. Another resident, dependent on staff for care, reported unbearable room temperatures and was denied access to fans or air conditioning. These events reflect the facility's failure to ensure a safe, clean, and comfortable environment.
Two residents who required assistance with ADLs did not receive timely or adequate care, resulting in one being left with overgrown toenails, a full and uncovered urinary catheter drainage bag, and dried feces on his body and bedding, while another had visibly soiled, overgrown, and jagged fingernails. Staff interviews and care plan reviews confirmed gaps in addressing hygiene and grooming needs, contrary to facility policy.
A resident receiving palliative care and prescribed Fentanyl experienced multiple extended periods without a documented bowel movement, with no evidence that Miralax was administered as ordered. Facility staff, including the DON and RN, were unable to produce or explain a bowel protocol, and the facility lacked a current bowel management policy, resulting in inconsistent care for the resident.
Surveyors found that three residents with chronic heart failure who required oxygen therapy did not have their oxygen tubing changed weekly as ordered by physicians. Observations showed that the tubing had not been changed for at least ten days, and the facility's policy lacked specific guidance on tubing change frequency, despite the DON stating that weekly changes were standard practice.
Surveyors observed multiple medication administration errors, including a nurse administering a Levothyroxine tablet that had been dropped on a dirty cart, another nurse applying Voltaren gel without using the required dosing card, and improper insulin administration with a Novolog Flexpen. These actions resulted in a medication error rate of 12%, exceeding the regulatory threshold.
A group of residents and the resident council president were unaware of the procedure for accessing the most recent survey results and plan of correction. When the posted survey results were reviewed, only a draft version marked "Not Final" was available, and no plan of correction was included. The administrator confirmed the absence of the final survey and plan of correction in the publicly accessible binder.
Surveyors found that the facility did not document or post the actual hours worked by RNs, LPNs, or CNAs on the daily nurse staffing sheets, leaving required columns blank despite facility policy and federal regulations mandating this information be available and updated for each shift.
The facility did not have a current three-day emergency menu or clear procedures to ensure food and water provision for staff and patients during emergencies. The Dietary Manager was unsure how to manage food service if staff were unavailable, and the emergency plan listed a different water vendor than the one actually contracted. These deficiencies resulted in a lack of clear, updated policies for subsistence needs during emergencies.
A gate leading from the patio area was found chained shut, blocking a designated emergency exit. This obstruction was observed and confirmed by the Maintenance Director, preventing proper egress in case of emergency.
The facility did not perform or document required monthly emergency lighting tests for several months, as confirmed by record review and the Maintenance Director.
The facility did not ensure that the kitchen hood was inspected and cleaned at least semi-annually as required by NFPA 96, with records showing only one cleaning report and the hood's cleaning sticker indicating the next cleaning was overdue. This was confirmed by the Maintenance Director.
The facility did not maintain or test its fire alarm system in accordance with NFPA standards, as most smoke detectors were found out of sensitivity or unserviceable and had not been replaced. There was also confusion and lack of documentation regarding the replacement of the fire alarm control panel, with discrepancies between reported and observed equipment. Additionally, the fire alarm control panel breaker lacked a required lock to prevent unauthorized disconnection.
A review of inspection records and staff interview revealed that the facility did not repair the outside bell on the automatic sprinkler system after it was found inoperable during the most recent annual inspection. The maintenance director confirmed the issue remained unresolved.
The facility did not transmit the fire alarm signal during required fire drills on the third shift or the following day for multiple instances, as confirmed by the Maintenance Director. This action did not meet regulatory requirements for conducting fire drills, which must include the transmission of a fire alarm signal and simulation of emergency fire conditions.
The facility did not ensure portable fire extinguishers were properly inspected and maintained according to NFPA 10, with one extinguisher lacking inspection records and another found overpressurized. These issues were confirmed by the Maintenance Director and could impact 15 occupants.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. After one RN resigned and another went on leave, the facility was left without adequate RN staffing despite attempts to recruit more RNs.
The facility failed to implement a comprehensive infection prevention and control program, leading to deficiencies in managing RSV and Norovirus outbreaks. The Infection Preventionist did not adequately track or document employee and resident illnesses, and no formal investigation was conducted for the outbreaks. This lack of adherence to established policies contributed to the facility's inability to control the spread of infections effectively.
The facility failed to ensure a qualified Infection Preventionist was working at least part-time and provided sufficient time to manage the Infection Prevention and Control Program. The designated IP was responsible for three facilities and primarily worked remotely, leading to deficiencies in outbreak surveillance, antibiotic stewardship, and immunizations. Specific residents did not receive necessary immunizations, and there was a lack of ongoing surveillance and outbreak investigations.
The facility failed to make grievance forms accessible to residents and family members and did not follow up on a resident's concerns about being woken up at night, which exacerbated his anxiety. The resident's care plan did not reflect his preferences for care timing, leading to ongoing dissatisfaction.
The facility failed to report and investigate an injury of unknown origin for a resident with multiple diagnoses, including alcohol-induced dementia and high blood pressure. Despite the resident experiencing increased right leg pain and an x-ray revealing a possible fracture, the facility did not report the injury to the State Agency, hold a Trigger Call, or conduct an internal investigation, violating their policies and procedures.
The facility failed to follow professional standards for medication administration for two residents, resulting in medications being given outside of physician-ordered parameters. One resident received metoprolol despite low blood pressure and heart rate, while another received amlodipine despite low blood pressure readings.
The facility failed to implement their policy for post-fall assessments for two residents reviewed for accidents and hazards. One resident with dementia and a history of falling experienced an unwitnessed fall resulting in a scalp laceration and hematoma, with no neurological assessment or new safety interventions. Another resident with dementia and orthostatic hypotension experienced multiple unwitnessed falls, with no neurological exams or new interventions added to the care plan to prevent future falls.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. Antibiotics were administered based on urine dip tests without waiting for culture results, and documentation did not meet McGeer Criteria for initiating antibiotics.
The facility failed to provide pneumococcal immunizations per CDC recommendations for two residents. One resident had not received the vaccine since 2016 despite consent and an order, while another had no documentation of receiving the last influenza or pneumococcal vaccines. The Infection Preventionist confirmed the immunizations were not up to date.
Failure to Provide Adequate Supervision and Proper Use of Assistive Devices Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and proper use of assistive devices for a resident who was at risk for falls. The resident, who had therapy recommendations for ambulation with a front-wheeled walker, contact guard assist, and a wheelchair to follow, was being assisted by a CNA during ambulation. The CNA reported using a gait belt and gripper socks, with one hand on the gait belt and the other pulling the wheelchair behind. When the resident expressed fatigue and a desire to sit, the CNA attempted to position the wheelchair but lost contact with the resident, resulting in the resident losing balance and falling sideways into a wall. The resident sustained a right femur fracture and required surgical intervention. Documentation and interviews revealed that the CNA was not fully aware of the specific contact guard assist requirement and believed the resident was an assist of one during ambulation. The incident report and progress notes confirmed that the plan of care, which required close supervision and specific assistive techniques, was not fully adhered to at the time of the fall. The lack of consistent application of the recommended supervision and assistive device use directly contributed to the resident's fall and subsequent injury.
Failure to Maintain Sanitary Food Service Conditions and Proper Sanitization
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions and professional standards for food service safety in the facility's kitchen and food storage areas. During a tour of the walk-in cooler, there was an accumulation of debris on the wire rack shelving, a dried yellow spill, and paper trash under racks and along the floor perimeter. The walk-in freezer also contained paper trash debris from date marking stickers. In the clean utensil drawer, crumbs were found along the back wall, and the Dietary Manager was unsure how often this area was cleaned. The stand-up mixer, covered with a plastic bag to keep it clean, had dried food debris on its underarm. Both the manual and electric can openers had significant accumulations of rust, pitting, and dark debris, and the pantry microwave had visible food debris on its interior top surface. Further deficiencies were noted in the facility's sanitation practices. Staff obtained sanitizer from the janitor's sink and filled spray bottles, but the test strips available for checking sanitizer concentration were expired. Testing revealed that one sanitizer spray bottle had a concentration of 0 to 50 ppm, while a bucket prepared by the Dietary Manager exceeded 500 ppm, indicating inconsistent and improper sanitizer levels. The Dietary Manager was unsure about the cause of this inconsistency. Additionally, in the clean pots and pans storage area, several pans were found stacked while still wet, without proper air drying, contrary to required procedures. These observations were corroborated by interviews with the Dietary Manager, who acknowledged uncertainty regarding cleaning schedules and procedures for several areas and equipment. The report references specific sections of the 2022 FDA Food Code, highlighting the requirements for cleanliness of food-contact and non-food-contact surfaces, proper use and testing of sanitizing solutions, and the necessity for air-drying equipment and utensils before storage. The documented failures in cleaning, sanitizing, and storage practices represent a deficiency in maintaining food safety standards as required by federal regulations.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures according to current guidelines and professional standards for two residents. For one resident with an indwelling urinary catheter and requiring maximal assistance, staff did not consistently use Enhanced Barrier Precautions (EBP) during high-contact care activities such as emptying the urinary catheter drainage bag and transferring the resident. Observations showed that staff either did not wear protective gowns as required or were unclear about when EBP should be used, despite CDC signage indicating the need for gowns and gloves during specific care activities. Additionally, the resident's care plan did not include interventions related to EBP, and the facility's infection control policy lacked procedures for EBP use. Another resident with end-stage renal disease, dementia, and a deep tissue injury was observed receiving wound care without staff donning gowns for EBP, as indicated by posted CDC guidance. During the wound care procedure, the nurse failed to maintain aseptic technique, including contaminating sterile supplies with gloved hands that had touched environmental surfaces, and retrieving gloves from a scrub pocket considered unclean. The nurse acknowledged these lapses in infection control practices during an interview. The facility also lacked an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in the water system. Observations revealed stagnant water lines, unused fixtures, and discolored water from infrequently used faucets. Staff interviews confirmed the absence of a routine flushing schedule for water fixtures and no environmental water testing as part of the water management program. The facility's water management policy referenced control measures and corrective actions but did not specify their implementation or documentation.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
The facility failed to provide dignified care and ensure privacy for two residents during personal care activities. One resident, who was admitted with diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression, was completely dependent on staff for all transfers, mobility, and personal care due to an indwelling urinary catheter and bowel incontinence. The resident was cognitively intact and expressed feelings of embarrassment and helplessness related to his dependence on staff and lack of privacy during care. During morning care, two CNAs were observed providing incontinence care to the resident, who was left uncovered and exposed while stool was being cleansed from his body. The shared bathroom door between the resident's room and an adjoining room was left open, allowing another resident to enter and view the exposed resident during care. The CNAs did not offer or assist with covering the resident at any time during the observation. Additionally, the urinary catheter drainage bag was not covered, and the resident's body was partially exposed during a transfer from bed to a recliner, with the bathroom door again left ajar. The Director of Nursing confirmed that the resident did not use the bathroom due to incontinence and catheter use, but staff used the bathroom during care provision. The DON acknowledged the importance of keeping the door closed to ensure privacy and dignity for both residents sharing the bathroom. The observations and interviews revealed repeated failures to maintain the resident's privacy and dignity during care, as required by resident rights regulations.
Failure to Maintain Safe, Comfortable, and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by two residents experiencing significant discomfort due to excessive heat and persistent urine odors in their living areas. One resident, with multiple diagnoses including dementia and end-stage renal disease, was found to be overheated and weak after wearing multiple layers of clothing on a hot day. Staff and the resident's power of attorney reported that the room was extremely hot, and the facility did not provide a fan, requiring the family to purchase one. The environmental services director confirmed there was no monitoring of room temperatures, and the facility had no documentation to ensure temperatures remained within regulatory limits. Additionally, the same resident's room was repeatedly noted to have a strong urine odor, with wet bed sheets and soiled pads left unaddressed after the resident was moved from bed. Staff acknowledged the presence of urine odor and wet linens, and the director of nursing confirmed that such linens should have been changed immediately. The resident's representative reported ongoing issues with urine odors and soiled pads, indicating a pattern of inadequate housekeeping and maintenance services. Another resident, who was dependent on staff for mobility and hygiene, reported that the temperature in his room was unbearable on several days, and requests for a fan or air conditioning were denied. The resident stated that he preferred to keep his door closed for privacy, which exacerbated the heat, and he was uncertain if a window air conditioner he ordered would be permitted. These findings demonstrate the facility's failure to provide adequate temperature control and maintain odor-free, comfortable living conditions for its residents.
Failure to Provide Timely ADL Care and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate activities of daily living (ADL) care for two dependent residents. One resident, who was cognitively intact and had multiple diagnoses including diabetes and bowel incontinence, was observed with overgrown toenails, a full and uncovered urinary catheter drainage bag containing dark yellow urine, and dried feces on his bedding and body. The resident had not been checked or changed since the previous evening, as staff reported honoring his request not to be disturbed overnight, but did not check on him at the beginning of the morning shift. The resident's care plan did not address bowel incontinence or nail care related to his diabetes diagnosis, and staff confirmed that nail care was the responsibility of licensed nurses, with no podiatrist available. Another resident, who required substantial assistance with bathing and personal hygiene and had mild cognitive impairment, was observed with visibly soiled, overgrown, and jagged fingernails. The resident's nails had dark coloring under the nail beds and were unkempt, with one thumbnail appearing sharp and jagged. The resident expressed resignation about the state of his nails when asked if he would prefer to have them cleaned and trimmed. His care plan noted a self-care performance deficit and the need for assistance with personal hygiene and oral care. Review of the facility's ADL policy indicated that residents unable to carry out ADLs should receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, observations and interviews revealed that these services were not consistently provided, resulting in residents being left with unmet hygiene and grooming needs.
Failure to Implement Bowel Protocol for Resident on Constipating Medication
Penalty
Summary
The facility failed to consistently implement a bowel protocol program for one resident who was admitted with chronic systolic congestive heart failure, protein-calorie malnutrition, and was receiving palliative and hospice care. The resident was prescribed Fentanyl, a medication known to cause constipation, and had a physician's order for Miralax to be administered as needed for constipation. However, medical record review showed multiple extended periods—ranging from four to over five days—without a documented bowel movement, and no documentation that Miralax was administered during these times. The Medication Administration Record for the month showed no evidence that the medication was given, despite the absence of bowel movements. Interviews with facility staff, including the DON, NHA, and a registered nurse, revealed that there was confusion and lack of clarity regarding the bowel protocol. The DON and NHA could not produce a current bowel protocol or explain the existing one, and the RN was unable to locate the protocol or specify the order of interventions. The Medical Director confirmed that the expectation was for staff to notify her after three days without a bowel movement and to administer Miralax as ordered, but this was not done. The facility did not have a current bowel policy in place at the time of the survey, and staff were unable to demonstrate consistent implementation of bowel management for the resident.
Failure to Maintain Sanitary Oxygen Tubing per Physician Orders
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of respiratory care, specifically regarding the maintenance of sanitary oxygen tubing for three residents who required oxygen therapy. Each resident had physician orders specifying that oxygen tubing should be changed weekly, with the tubing dated and initialed at each change. However, observations revealed that the oxygen tubing for all three residents had not been changed for at least ten days, as the tubing was last dated as changed on 6/16/25, despite observations occurring on 6/24/25 and 6/26/25. The residents involved had diagnoses including chronic diastolic and systolic congestive heart failure and were documented as requiring oxygen therapy per their care plans and physician orders. Interviews with the Director of Nursing confirmed that the facility's practice was to change oxygen tubing weekly, but the facility's written policy on oxygen administration did not specify the frequency for changing tubing. The lack of adherence to physician orders and the absence of clear policy guidance contributed to the failure to maintain sanitary oxygen tubing for the affected residents.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 12% based on 3 errors out of 25 observed opportunities. One incident involved a registered nurse preparing Levothyroxine for a resident, during which the tablet was dropped onto the top of a medication cart that was acknowledged as dirty and not disinfected. The nurse picked up the tablet with gloved hands, without performing hand hygiene, and administered it to the resident instead of discarding it and using a new tablet, as required. Another incident involved a nurse preparing Diclofenac Sodium (Voltaren) gel for a resident's knees without using the required dosing card to measure the correct 4-gram dose. The nurse was unaware of the dosing card's existence and could not confirm the correct amount was administered. A third incident involved the administration of fast-acting insulin using a Novolog Flexpen, where the nurse changed the needle after priming and did not follow the manufacturer's instructions to keep the needle in the skin for six seconds after the dose counter reached zero, potentially resulting in an incomplete dose. These actions were observed and confirmed through interviews and record reviews.
Failure to Provide Accessible Survey Results and Plan of Correction
Penalty
Summary
The facility failed to honor residents' rights to examine the results of the most recent survey conducted by Federal or State surveyors, as well as the associated plan of correction. During a confidential group meeting with six residents, it was revealed that none of the residents were aware of the procedure for accessing the survey results or knew where these results were posted. The resident council president also confirmed a lack of knowledge regarding the location of the last survey results. Upon inspection with a resident, a binder containing survey results was found hanging on the wall. However, the most recent survey displayed was marked "Not Final" on each page, and there was no plan of correction included. The Nursing Home Administrator confirmed that the binder did not contain a final copy of the last annual survey or the required plan of correction, indicating that the facility did not make these documents readily accessible as required.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to comply with federal requirements for posting daily nurse staffing information. On multiple occasions, surveyors observed that the Nurse Staffing Sheets posted in a prominent location did not include the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Certified Nurse Aides (CNAs) for any shift. The columns designated for recording these actual hours were left blank for the reviewed dates. This omission was confirmed during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), who acknowledged that the actual hours worked were not documented as required. A review of the facility's own policy indicated that the Nurse Staffing Sheet should be updated daily to reflect actual hours worked, including adjustments for staff absences or call-outs, and should include all nursing staff paid by the facility, including contract staff. Despite this policy, the posted sheets did not contain the required information, resulting in noncompliance with federal regulations regarding nurse staffing data transparency.
Failure to Establish and Maintain Emergency Subsistence Policies and Procedures
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during emergencies, as required by federal regulations. During an interview, the Dietary Manager was unable to confirm the existence of a three-day emergency menu and stated that food provisions would be based on the regular menu cycle. The Dietary Manager also expressed uncertainty about how the facility would manage food service if dietary staff were unable to work due to weather conditions. It was noted that a three-day emergency menu had previously existed but was not re-established after a change in food vendors. Additionally, a review of the facility's emergency preparedness plan revealed inconsistencies regarding water supply arrangements. The written policy indicated reliance on one vendor for emergency water provision, while the Administrator reported having a contract with a different vendor not reflected in the plan. These deficiencies indicate a lack of clear, updated, and actionable procedures to ensure the availability of food, water, and other essential resources for staff and patients in the event of an emergency.
Obstructed Emergency Exit Due to Chained Patio Gate
Penalty
Summary
A deficiency was identified when, during an observation, a gate providing exit from the patio area was found to have a chain wrapped around it and the adjoining fence, which prevented the gate from being used as an emergency exit. This obstruction to the means of egress was discovered at approximately 11:37 AM and was confirmed by the Maintenance Director at the time of the observation. The report does not mention any specific residents or staff being directly affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Failure to Conduct Monthly Emergency Lighting Tests
Penalty
Summary
The facility failed to conduct monthly emergency lighting tests for the months of June 2024 through October 2024, as required by regulations. This was identified during a record review on June 25, 2025, when no documentation of the required testing was available. The Maintenance Director confirmed that the records for these months were not provided at the time of the survey exit. This deficiency could affect all occupants in the event of a power failure, as automatic emergency lighting is required to be tested regularly to ensure proper function.
Failure to Perform Required Semi-Annual Kitchen Hood Cleaning
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Specifically, the kitchen hood was not inspected or cleaned at least semi-annually as required. Record review showed only one hood cleaning report dated October 2024, and the cleaning sticker on the hood indicated that the next cleaning was due in April 2025. This deficiency was confirmed during an interview with the Maintenance Director at the time of discovery. No information was provided regarding specific patients or their medical conditions in relation to this deficiency.
Deficient Fire Alarm System Testing, Maintenance, and Documentation
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to NFPA 70 and NFPA 72 standards. During record review, it was found that the most recent annual fire alarm inspection and sensitivity reports indicated that most smoke detectors were out of sensitivity or unserviceable and needed replacement. When questioned, the Maintenance Director (MD) confirmed that these issues had not been corrected. Documentation provided showed that some components such as duct detectors, key switches, and panel parts were replaced, but there was confusion regarding whether the fire alarm control panel (FACP) itself had been replaced. Further review revealed a discrepancy between the inspection report, which listed an Edwards EST Panel, and the observed installed panel, which was a Kidde FX Series. No evidence was provided to clarify if the deficiencies noted in the inspection and sensitivity reports had been addressed or to explain the discrepancies regarding the FACP. Additionally, it was observed that the breaker for the Fire Alarm Control Panel did not have a device to prevent unauthorized disconnection, such as a circuit breaker lock, as required by NFPA 72. This finding was confirmed by the MD at the time of discovery. No further information was provided to indicate that this issue had been resolved.
Failure to Repair Sprinkler System Alarm After Inspection
Penalty
Summary
The facility failed to provide required maintenance and testing for its automatic sprinkler system in accordance with NFPA 25. During a record review on June 25, 2025, it was found that the most recent annual sprinkler inspection, dated March 25, 2025, documented that the outside bell failed to operate. An interview with the maintenance director confirmed that this issue had not been fixed. This deficiency was identified through both documentation and staff confirmation.
Failure to Transmit Fire Alarm Signal During Fire Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with regulatory requirements, specifically by not transmitting the fire alarm signal during fire drills on the third shift or immediately the next day for several documented dates. This deficiency was identified through record review and confirmed by the Maintenance Director. The report notes that fire drills are required to include the transmission of a fire alarm signal and simulation of emergency fire conditions, but on multiple occasions, this procedure was not followed as required.
Failure to Maintain and Inspect Portable Fire Extinguishers per NFPA 10
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were selected, installed, inspected, and maintained in accordance with NFPA 10 standards. During an observation on June 25, 2025, a fire extinguisher located in the patio area was found to have no record of inspection. Additionally, another fire extinguisher located behind the 200 wing nurses station was observed to be overpressurized. These deficiencies were confirmed by the Maintenance Director at the time of discovery. The deficient practices could affect 15 occupants in the event of a fire, as noted in the findings.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported that the facility had 2 RNs employed in addition to the DON until one RN resigned on 3/08/2024. Despite attempts to recruit more RNs, no new hires were made. The facility assessment indicated that staffing should include two full-time RNs working 10-hour shifts, 4 days a week, with coverage 7 days a week. However, the March 2024 master schedule showed that after the resignation, the facility was left without an RN for the required hours starting on 3/16/2024. The April 2024 schedule further reflected that the remaining RN began a leave of absence on 4/24/2024, exacerbating the staffing deficiency.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, leading to deficiencies in preventing, identifying, reporting, investigating, and controlling infections and communicable diseases among residents, staff, volunteers, and visitors. Specifically, the facility did not adequately investigate and document outbreaks of RSV and Norovirus that occurred between December 2023 and March 2024. The Infection Preventionist, DRC C, acknowledged that employee and resident illnesses were not tracked on a specific surveillance tool but were instead scattered across various communication platforms and records, making it difficult to manage and control the outbreaks effectively. During interviews, it was revealed that the Director of Regulatory Compliance (DRC) C, who was responsible for infection surveillance, found it challenging to determine the validity of employee call-ins and to gather additional information from employees. The Previous Director of Nursing (PDON) D confirmed that no formal investigation into the RSV and Norovirus outbreaks was completed, and no documentation was available to confirm that an outbreak investigation had been conducted. This lack of documentation and follow-up indicates a significant gap in the facility's infection control practices. The review of the Employee Line Listings from January to May 2024 showed multiple instances where employees called off work due to illness without any follow-up or tracking documentation to determine if residents had been exposed to an illness. Additionally, the facility's policies on infection outbreak response and investigation, infection prevention and control program, and employee work restrictions were not adhered to, as evidenced by the lack of outbreak investigation and inadequate tracking of employee illnesses. This failure to follow established policies contributed to the facility's inability to control the spread of infections effectively.
Inadequate Infection Preventionist Presence and Oversight
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, provided sufficient time to perform the IP role, and was present to properly manage the Infection Prevention and Control Program (IPCP). The Director of Regulatory Compliance (DRC) was designated as the IP for the facility but was responsible for overseeing three facilities and primarily performed her duties remotely. The DRC was only physically present at the facility one to two days a week, which was insufficient to meet the requirements of the IPCP. This lack of adequate presence and oversight led to deficiencies in outbreak surveillance, antibiotic stewardship, and immunizations. The facility's Antibiotic Stewardship Program was not properly implemented, as evidenced by the treatment of three residents with antibiotics without appropriate indications for use. Additionally, the IP did not ensure that eligible residents received the pneumococcal vaccine, and there was a failure to keep all resident immunization statuses up to date. Specific residents were identified as not having received the necessary immunizations, highlighting the gaps in the facility's infection control practices. Furthermore, the facility's Infection Control Program lacked ongoing surveillance for employee illnesses and did not conduct outbreak investigations for significant events, such as an RSV outbreak and a Norovirus outbreak. The facility's policy outlined the responsibilities of the IP, including surveillance, reporting, and managing infections, but these were not adequately fulfilled due to the insufficient presence and involvement of the designated IP. This failure to adhere to the established policies and guidelines resulted in significant lapses in infection prevention and control within the facility.
Failure to Provide Accessible Grievance Forms and Follow Up on Resident Concerns
Penalty
Summary
The facility failed to make grievance forms readily available to all residents and family members, and did not follow up with one resident's grievances. Observations on multiple dates revealed that the plastic tray labeled for grievance forms near the nurses' station was consistently empty and situated at a height inaccessible to residents in wheelchairs. Additionally, there were no instructions on the posting regarding who would follow up on the grievances and the expected time frame for follow-up. An LPN was unable to locate any grievance forms when asked, indicating a systemic issue in the availability of these forms. A resident, who was cognitively intact, reported dissatisfaction with the follow-through on his concerns about being woken up at night, which exacerbated his anxiety. The resident had submitted grievances about being woken up early to clean his fecal collection container and requested that this care be performed between 7 AM and 3 PM. However, the care plan did not reflect these preferences, and there was no indication that the resident was content with the plan of care. The resident's care plan was updated to include a note about his changing preferences, but the specific request to sleep in until he naturally wakes up was not addressed, leading to ongoing dissatisfaction and anxiety for the resident.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement policies and procedures for reporting an injury of unknown origin for a resident (R16). R16 was admitted with multiple diagnoses, including non-traumatic subarachnoid hemorrhage, rhabdomyolysis, alcohol-induced dementia, high blood pressure, weakness, and hearing loss. On 1/25/24, a progress note indicated that R16 was very weak, unsteady, and experiencing increased right leg pain. The resident was sent to the hospital for an x-ray, which revealed a deformity of the right pubic bone that could relate to an acute or chronic fracture. A follow-up evaluation confirmed a fracture of multiple pubic rami with routine healing. Despite these findings, the facility did not report the injury of unknown origin to the State Agency, did not hold a Trigger Call, and did not conduct an internal investigation into the injury. During interviews, the Director of Nursing and the Nurse Consultant confirmed that there was no investigation into the fracture identified in R16's x-ray. The facility's policies, including the Trigger Event policy and the Abuse and Neglect Policy, require reporting all injuries of unknown origin to the department of public health and conducting internal investigations. However, these procedures were not followed in this case, leading to the deficiency. The failure to report and investigate the injury of unknown origin was a clear violation of the facility's policies and procedures designed to protect residents' health and welfare.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for two residents, resulting in medications being administered outside of the physician-ordered parameters. Resident #6, a [AGE] year-old female with hypertension, had multiple instances where her blood pressure and heart rate were below the prescribed thresholds, yet metoprolol was still administered. Specifically, on 5/1/24, her blood pressure was 98/60; on 5/2/24, her heart rate was 64; and on 5/5/24, her blood pressure was 104/54 with a heart rate of 58, but the medication was given each time regardless of these readings. Resident #36, a [AGE] year-old male with hypertension, also experienced similar issues. His April Medication Administration Record revealed that amlodipine was administered despite his blood pressure being below the ordered parameters on multiple occasions. For instance, on 4/9/24, his blood pressure was 108/70; on 4/10/24, it was 110/70; and on 4/19/24, it was 102/80. Additionally, on 4/25/24, his blood pressure readings were 108/58 and 98/54, yet the medication was still administered. The Director of Nursing acknowledged that the nursing staff did not follow the physician's orders and stated that the staff would receive education to ensure compliance with medication administration protocols.
Failure to Implement Post-Fall Assessments and Safety Interventions
Penalty
Summary
The facility failed to implement their policy for post-fall assessments for two residents reviewed for accidents and hazards. Resident #6, a female with dementia and a history of falling, experienced an unwitnessed fall resulting in a scalp laceration and hematoma. Despite the severity of the injury, no neurological assessment or post-fall assessment was conducted, and no new safety interventions were implemented. Additionally, there were no orders for nursing to monitor and assess the resident's scalp laceration, contrary to the facility's policy for head injuries. Resident #14, who had diagnoses including dementia and orthostatic hypotension, experienced multiple unwitnessed falls. After a fall in the bathroom and another in his room, no neurological exams were conducted, and no new interventions were added to the care plan to prevent future falls. The care plan did not address the causative factors of the falls, and subsequent progress notes lacked details surrounding the incidents. The facility's failure to follow their own policies for post-fall assessments and care planning contributed to the deficiencies noted by the surveyors.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in inappropriate antibiotic use for three residents. Resident #14 was administered Cipro for a suspected urinary tract infection (UTI) based on a urine dip test, without waiting for culture results. The culture later indicated contamination, and the antibiotic was discontinued after three doses. Documentation did not provide adequate symptoms to meet McGeer Criteria for initiating antibiotics prior to culture results. Resident #18 exhibited confusion and unusual behavior, leading to a urine dip test that was positive for leukocytes, nitrates, and blood. Despite not meeting McGeer Criteria, the resident was started on nitrofurantoin before culture results were available. The culture later showed resistance to the prescribed antibiotic, necessitating a change to Amoxicillin. Documentation did not justify the initial antibiotic use based on McGeer Criteria. Resident #6 showed increased confusion and hallucinations, prompting a urine dip test that was positive for leukocytes and nitrites. An antibiotic was started before culture results, which later indicated contamination. The facility's documentation did not provide sufficient symptoms to meet McGeer Criteria for initiating antibiotics. The Director of Regulatory Compliance confirmed that the facility's antibiotic stewardship program was not followed as required, leading to inappropriate antibiotic use.
Failure to Provide Pneumococcal Immunizations Per CDC Recommendations
Penalty
Summary
The facility failed to provide the pneumococcal immunization per consent and CDC recommendations for two residents. Resident #37, a female admitted on [DATE], had not received a pneumococcal vaccine since 9/9/2016, despite having a signed consent dated 4/1/24 and an order to administer the vaccine every 5 years. Resident #191, a female admitted on [DATE], had no documentation of receiving the last influenza or pneumococcal vaccines, even though a signed consent was provided on 5/1/24 and an order to administer the influenza vaccine annually was in place. The Director of Nursing reported that the Director of Regulatory Compliance, who is also the Infection Preventionist, was responsible for the immunization program but was unable to locate the immunization tracking information. The Infection Preventionist confirmed that the pneumococcal immunizations were not up to date and was in the process of updating the residents' immunization status. The facility's policies on infection prevention and control, as well as pneumococcal vaccination, were not followed, leading to the deficiency in providing the required immunizations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stephenson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinecrest Medical Care Facility | 19.7 mi | ★★★★★ | 0 | 0 |
| Menominee Health Services | 20.1 mi | ★★★★★ | 3 | 0 |
| Newcare | 22.9 mi | ★★★★★ | 14 | 0 |
| Luther Home | 23.4 mi | ★★★★★ | 16 | 0 |
| Rennes Health And Rehab Center-east | 24.9 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Roubal Care And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.