Roberta Trails of Journey LLC

In the surveyor’s words

From the most serious findings on record at Roberta Trails of Journey LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF867Dec 21, 2023

  Based on observations, staff interviews, and review of the Quality Assessment and Performance Improvement (QAPI) Plan 2023, the facility failed to have an effective Quality Assurance (QA) program that developed and implemented actions to repair and/or replace the flooring throughout the facility in a timely manner. This failure had the potential to affect 70 residents. Findings include: Observation of Hall Two on 12/20/2023 at 12:21 pm revealed the flooring had soft areas and breaks/missing tiles down the entire hallway. During observations with the Maintenance Director on 12/21/2023 beginning at 10:42 am, he confirmed the soft/spongy flooring and missing tiles on Hall Two and throughout the common areas of the facility. […]

• No harm, potential for more than minimal, patternF755Aug 13, 2026

  Based on observations, interviews and review of policy titled, Medication Administration, the facility failed to ensure that the narcotics count was documented at the beginning of each shift on three of three medications carts (Hall 1 cart, Hall 2 cart and Hall 3 cart). The deficient practice increased the risk of inaccurate accountability of controlled substances and increased risk of diversion or unauthorized use.Findings include:Review of policy titled, Medication Administration dated 02/01/2024 and revised 02/14/2026 documented under the section, Policy Explanation and Compliance Guidelines number 18 that, If medication is a controlled substance, sign narcotic book. […]

• No harm, potential for more than minimal, patternF880Feb 10, 2021

  Based on observation, interview, product page review, and policy review, the facility failed to ensure the product used by two of four housekeeping staff to disinfect high touch areas was effective against the COVID-19 virus and was used effectively by staff. This failure had the potential for cross contamination and infection of residents and/or staff that may come in contact with ineffectively cleaned/disinfected surfaces on the halls where the two housekeepers were assigned. Findings include: In an interview on 2/10/21 at 10:55 a.m. regarding what products were used and how high touch areas of the facility were cleaned and disinfected, Housekeeper (Hskpr) DD responded by stating they used an orange cleaner. Hskpr DD was then observed on 2/10/21 at 10:55 a.m. […]

• No harm, potential for more than minimal, isolatedF600Aug 13, 2026

  Based on staff interviews, record review, and a review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect the resident's right to be free from abuse for one of 39 sampled residents (R) (R66), by a staff member. The deficient practice had the potential to affect resident psychosocial health and safety. Findings include:Review of the facility's policy titled, Abuse, Neglect, and Exploitation last revised 03/05/2026, documented on page 1: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Review of the most recent Quarterly Minimum… […]

• No harm, potential for more than minimal, isolatedF628Aug 13, 2026

  Based on interview, record review, and review of the facility policy titled, Discharge Planning Process, reviewed 3/20/25, the facility failed to document a recapitulation of stay for one of 19 sampled residents (R62). The deficient practice increased the risk of insufficient and/or omitted care requirements with the receiving facility for R62.Findings include:Review of the electronic medical record (EMR) for R62 revealed there was only an incomplete face sheet and a Discharge Minimum Data Set (MDS) assessment, dated 07/16/2026, which was the day he was admitted to the facility and then transferred to another unnamed skilled nursing facility (SNF). […]