Roubal Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Roubal Care and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880May 12, 2022

  Based on interview and record review, the facility failed to appropriately implement effective infection control measures to prevent the transmission of influenza A (a highly transmissible respiratory infection) resulting in three Residents (#33, #250 and #255) expiring in the facility due to influenza A with a total of 24 residents residing in the 39-bed facility becoming infected with influenza A. The facility failed to: 1) Promptly identify an outbreak of acute respiratory illness (influenza A). 2) Promptly implement transmission-based precautions for residents with signs and symptoms of acute respiratory illness (influenza A) to prevent the spread of infection. […]

• Actual harm, isolatedF689Jun 26, 2025

  Based on interview and record review, the facility failed to ensure adequate supervision and proper use of assistive devices (gait belt and wheelchair) to prevent a fall with major injury (fractured femur) for one Resident #37 (R37) out of one resident reviewed for falls. This deficient practice resulted in harm when R37 fell while ambulating with staff and subsequently fractured his femur requiring a surgical hip repair. Findings include:All times noted are in Eastern Daylight-Saving Time (EDST), unless otherwise noted. Resident #37 (R37) Review of R37's Progress Notes revealed the following, in part: 1/12/2025 15:44 ([:44 Central Standard Time (CST)]: Resident ambulating in hall with staff assistance, utilizing walker, wheelchair to follow. […]

• Actual harm, isolatedF686May 12, 2022

  Based on observation, interview and record review, the facility failed to appropriately assess and provide treatment and services to prevent the development of a pressure injury for one Resident (#23) of one resident reviewed for pressure injuries. This deficient practice resulted in harm when Resident #23 developed a new, facility-acquired Stage 3 (full-thickness tissue loss) pressure injury. Findings include: All times recorded in eastern daylight time (EDT). A review of Resident #23's most recent Minimum Data Set (MDS) Assessment, dated 3/16/2022, revealed Resident #23 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF726Jul 29, 2026

  All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review, the facility failed to ensure five Certified Nurse Aides (CNA) [ F G H I and J] of five CNA's reviewed for competencies had the required yearly competency trainings, including demonstration in skills and techniques necessary to care for residents.Findings include:A review of facility staff personnel records revealed CNA F was hired on 3/13/22. CNA Fs personnel record did not demonstrate yearly competency training.A review of facility staff personnel records revealed CNA G was hired on 11/21/24. CNA Gs personnel records did not demonstrate yearly competency training.A review of facility staff personnel records revealed CNA H was hired on 6/30/23. […]

• No harm, potential for more than minimal, widespreadF727Jul 29, 2026

  All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review the facility failed to ensure a Registered Nurse (RN) was available for eight consecutive hours during a 24-hour period. Findings include:Review of the nursing schedule documents from April 1 through June 30th revealed no RN coverage on the following dates and times:Friday, April 3rd at 6:00 p.m. through Monday, April 6th 6:00 a.m.Friday, April 10th at 4:00 p.m. through Monday, April 13th at 6:00 a.m.Friday, May 1st at 4:00 p.m. through May 4th at 6:00 p.m.Friday, May 6th at 6:00 p.m. through May 11th at 6:00 a.m.Friday, May 15th at 4:00 p.m. through May 18th at 8:00 a.m.Friday, May 29th at 4:00 p.m. through June 1st at 6:00 a.m.Friday, June 12th at 4:00 p.m. […]