Roubal Care and Rehabilitation Center

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. This citation pertains to intake #3072295 & #3072396 Based on interview and record review, the facility failed to assess, monitor, and document a change in condition per standards of practice for one Resident (#38) of twelve residents reviewed for quality of care.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Ensure the use of infection control measures were practiced according to current guidelines and professional standards of practice for three Residents (#31 and #13) of 11 residents reviewed for infection control practices. Have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a dignified care experience for two Residents (#31 and #14) of two residents reviewed for dignity, resulting in R31 expressing feelings of humiliation and helplessness.

Inspectors wroteBased on interview and record review, the facility failed to maintain facility living areas odor free and with comfortable temperatures for two Residents #7 and #31 (R7 and R31) of 16 residents reviewed for a safe, clean, comfortable environment. This deficient practice resulted in resident dissatisfaction with unbearably hot living conditions and the smell of urine in R7's room.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the timely provision of ADL (Activities of Daily Living) care for two Residents (#31 and #25) of two residents reviewed for ADL care.

Inspectors wroteBased on interview and record review, the facility failed to consistently implement a bowel protocol program for one Resident (R32) of 2 Residents reviewed for bowel function in a total sample of 12 residents. This deficient practice resulted in extended periods of time when R32 had no documented bowel movement, with increased risk for pain and discomfort and/or the risk for medical complications such as bowel impaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary oxygen tubing for three Residents (R6, R32 and R34) of four Residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% for three Residents (R6, R7 & R 1) of 9 residents reviewed for medication administration. This deficient practice resulted in a medication administration error rate of 12.00%, based on 3 medication errors in 25 opportunities for error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the residents' rights to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect. This deficient practice affected all 36 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual hours worked by licensed and unlicensed nursing staff on the daily Staff Posting Information.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for a least 8 consecutive hours a day, 7 days a week.

Inspectors wroteThis citation is related to intake # MI00-138390 Based on interview and record review, the facility failed to 1). Implement a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors and 2.) investigate and document the outbreak of gastrointestinal illness and respiratory illness among staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and was present to properly assess, implement, and manage the Infection Prevention and Control Program resulting in the lack of outbreak surveillance and investigation, antibiotic stewardship, and immunizations.

Inspectors wroteThis citation is related to intake # MI00-142770 Based on observation, interview, and record review, the facility failed to make grievance forms readily available to all resident's and family members, and failed to follow up with 1 of 3 resident's (Resident #4) reviewed for grievances.

Inspectors wroteThis citation pertains to intake # MI00138390 Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of an injury of unknown origin for 1 resident (R16) out of 4 residents reviewed for abuse and neglect.

Inspectors wroteThis citation pertains to intake MI00138390 and MI00139816 Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 2 of 15 residents (Resident #6 and #36), reviewed for the provision of nursing services, resulting in medications being administered outside of the physician ordered parameters.

Inspectors wroteThis citation pertains to intake #MI00138390 Based on observation, interview, and record review, the facility failed to implement their policy for post-fall assessments for 2 of 4 resident's (Resident #6 and Resident #14) reviewed for accidents and hazards.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program and ensure that residents who required an antibiotic were prescribed the appropriate antibiotic for 3 of 7 Residents (#14, #18, and #6) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal immunization per consent and the recommendation by the Centers for Disease Control and Prevention (CDC) for 2 of 5 residents (Resident #37 and #191) reviewed for immunizations, resulting in residents not receiving the pneumococcal immunization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ qualified staff with the appropriate competencies, skill sets, and credentials to supervise and carry out the functions of the food and nutrition service department. This deficient practice resulted in the potential for clinical and operational dietary needs to be compromised or unmet for all 39 residents living at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to properly clean areas with a potential to contaminate food during preparation. B. Failing to ensure food preparation surfaces in the dietary department were properly disinfected. C. Failing to ensure that refrigerated potentially hazardous foods brought in by visitors were dated and discarded on or before the expiration date. This deficient practice had the potential to result in food borne illness among any or all 39 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store drugs and biologicals in locked compartments, with keys accessible only to authorized personnel, on three halls out of three halls reviewed for medication storage. This deficient practice resulted in the potential diversion of medication, and uncontrolled access by facility staff to physician prescribed and over-the-counter medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared in the prescribed texture to meet individual needs for four Residents (R16, R20, R27, and R36) of 5 residents reviewed for food served in the proper form. This deficient practice resulted in the delivery of food of inappropriate consistency for the prescribed diet with the potential for choking, aspiration (accidental breathing of food or fluid into the lungs) and complications including aspiration pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards including access to the electronic bed and recliner chair remote controls and a potentially hazardous, inedible denture cleanser tablet for one Resident (R92) out of five residents reviewed for accidents and hazards. This deficient practice resulted in the potential for unsafe bed and chair repositioning, partial ingestion of a denture cleanser tablet, poison control notification, and additional physical monitoring for R92.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: attempt alternatives prior to the use of a bedrail, appropriately assess resident risk of entrapment prior to use of a bedrail, and obtain a physician order for the bed rail prior to use of a restraint for one Resident (R92) out of one resident reviewed for safe bedrail usage. This deficient practice resulted in the potential for bedrail entrapment of a cognitively impaired resident, and the potential for unnecessary use of bedrails.