Robinson Rehab and Nursing

Inspectors wroteBased on interview and record review, the facility failed to provide increased staff supervision in order to protect a resident from resident-to-resident abuse for one (R2) of three residents reviewed for abuse in the sample of three. This failure resulted in R1 threatening, hitting and throwing water on R2, and with R2, upon staff directives, curtailing his normal activities to try to avoid R1.

Inspectors wroteBased on interview and record review, the facility failed to report resident-to-resident physical abuse to local law enforcement for one resident (R2) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to identify and thoroughly investigate allegations of resident-to-resident abuse and failed to ensure residents were not at risk for further abuse for one resident (R2) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the dish machine and 3 compartment sink were effectively sanitizing the dishes and stationary equipment. This has the potential to affect all 59 residents residing in the facility. The Findings Include: During the initial tour of the kitchen on 11/18/25 at 9:45am, V4 (Cook) measured the sanitizer levels of dish machine with a quaternary sanitizer test strip. The strip measured 0 part per million (ppm). V4 then retrieved chlorine test strips and tested the dish machine again with a 0 ppm reading. A bucket of sanitizer was then tested with the quaternary test strip and a 0 ppm reading was obtained. A dishwasher Temperature Log and Temp/Chemical Sanitizing Machine dated November 2025 was provided and was filled out through the current day 11/18/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow policy and procedure for infection control practices for 4 of 16 residents (R13, R54, R57, and R59) reviewed for infection control in the sample of 35. The Findings Include:1. R54's admission Record documented an Initial admission Date of 11/12/2024. R54's admission Record documents the following diagnoses: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, polyosteoarthritis, neuromuscular dysfunction of bladder, pain in right knee, major depressive disorder, hypotension, and acute kidney failure. R54's Order Summary Report dated 11/20/2025 documented an order for suprapubic catheter change monthly on the 7th - urologist to change. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to provide supervision and implement effective interventions to prevent falls for 1 (R1) of 3 residents reviewed for falls in the sample of 12. This failure resulted in R1 sustaining a fall that caused a fracture of left knee and large hematoma of scalp and a right parietal subarachnoid hemorrhage. This past non-compliance occurred on from [DATE] to [DATE]. Findings Include:R1's face sheet documents an original admission date of [DATE]. R1 has diagnoses in her electronic health record including, but not limited to dementia, dorsalgia, history of falling, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, and difficulty in walking. [...]

Inspectors wroteBased on interview and record review, the facility failed to respond to residents' requests for assistance in a timely manner to promote dignity and respect for 1 (R1) of 4 residents reviewed for call light response in the sample of 4. This failure resulted in R1 having to urinate on herself, causing her feelings of discomfort, anxiety, humiliation, and embarrassment. Findings Include: R1's admission Record documented an admission date of 4/27/25 and included diagnoses of morbid (severe) obesity due to excess calories, spinal stenosis, need for assistance with personal care, presence of right artificial hip joint, pain in right hip, presence of artificial knee joint, bilateral, essential tremor, anxiety, and muscle weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were scheduled/available to provide timely care to meet residents' needs. This failure has the potential to affect all 60 residents residing in the facility. Findings Include:1. R1's admission Record documented an admission date of 4/27/25 and included diagnoses of morbid (severe) obesity due to excess calories, spinal stenosis, need for assistance with personal care, presence of right artificial hip joint, pain in right hip, presence of artificial knee joint, bilateral, essential tremor, anxiety, and muscle weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain air conditioning equipment and provide comfortable temperatures for 21 of 21 residents (R1-R21) reviewed for environment in the sample of 21. Findings Include: On 06/27/2025 at 11:30 A.M. while entering the building fans were observed in resident rooms, and lights were off in the dining room. On 06/27/2025 at 11:56 A.M. V1 (Administrator) stated that there was a recent problem with the air, but it was fixed yesterday 06/26/2025. On 06/27/2025 at 1:12 P.M. V3 (Agency Registered Nurse) stated that it is cooler in the facility. V3 stated that it was hot in the building but not unbearable. V3 stated there were fans in the hallway blowing air. V3 stated she is not aware of any residents that had heat related issues. On 06/27/2025 at 1:20 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly assessments were completed within the required time frames for nine (R13, R16, R25, R27, R47, R48, R49, R52 and R54) of nine residents reviewed for quarterly assessments in a sample of 35. The Findings Include: R13's Face Sheet documented an admission date of 1/13/23. R13's most recent completed and submitted quarterly Minimum Data Set (MDS) Section A documented an Assessment Reference Date (ARD) of 4/27/24. The next quarterly MDS Section A was initiated with an ARD of 7/28/24 but had not been completed or submitted as of the date of this review on 08/16/24. This indicates more than 92 days between completion of assessments and shows R13's quarterly assessment had not been completed/submitted within 14 days after the ARD of 7/28/24. R16's Face Sheet documented an admission date of 10/12/22. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure comprehensive assessments were completed in accordance with required time frames for two (R12, R44) of two residents reviewed for comprehensive assessments and timing in the sample of 35. The Findings Include: R12's Face Sheet documented an admission date of 7/29/22. R12's previous Comprehensive Minimum Data Set (MDS) assessment documented an Assessment Reference Date (ARD) of 7/4/23. R12's most recent completed and submitted Quarterly MDS assessment, Section A documented an Assessment Reference Date (ARD) of 4/7/24. R12's current Comprehensive MDS assessment Section A documented it had been initiated with an ARD of 7/2/24 but documents no completion date as of the date of this review on 08/16/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide therapeutic diets as ordered for 1 (R47) of 2 residents reviewed for dietary supplements in the sample of 35. Findings Include: R47's Face Sheet documented an admission date of 11/13/23 and included the following diagnoses of unspecified protein-calorie malnutrition, dysphagia, oropharyngeal phase. R47's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. This same MDS documents under section I Active Diagnoses, a diagnosis of I5600 Malnutrition (protein, calorie) risk of malnutrition. R47's Physician Order Summary dated 5/13/2024 documented high protein pudding. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adaptive utensils for one (R21) of one resident reviewed for assistive devices in the sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain aseptic technique while performing urinary catheter care and implement transmission based precautions for two (R23, R47) of two residents reviewed for infection control in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement progressive person centered interventions for fall prevention for 1 (R1) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R1 experiencing 4 falls between 2/20/24 and 3/3/24 which required emergency room evaluation and/or treatment for injuries that included skin tears to right arm, a right orbital fracture, head lacerations, and baseball size hematoma to the head. Findings Include: R1's admission Record documented an initial admission date to the facility as 9/22/23. R1 is documented on this same record as being [AGE] years old with diagnoses including but not limited to: Unspecified Dementia, unspecified severity, with agitation; Type 2 Diabetes Mellitus; Major Depressive Disorder; Insomnia; Muscle Weakness; and Cognitive Communication Deficit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call system was available for resident use. This failure has the potential to effect all 60 residents residing in the facility. Findings Include: On 10/17/23 at 10:00 AM, V1 (Administrator) stated that the electronic call light system is not working. V1 stated after ordering new parts which failed to correct the problem, a whole new call light system has been ordered. The current plan is that they are telling residents to ring their hand bell, along with using the call light. V1 stated that the call light system will light up, but it doesn't make a sound. Residents are told to use both the call light and the bell, or just the bell. The staff then go down the hall to find who's bell it is, and if they use the call light it helps them respond quicker. [...]

Inspectors wroteBased on interview and record review the facility failed to provide timely staff response to call lights for five residents of five residents (R12, R40, R45, R46, R53) reviewed for call lights in the sample of 34.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure that call bells are placed within reach of residents for 2 of 15 residents (R3 and R25) reviewed for call lights in a sample of 34. The Findings Include: 1. R25's admission record documents an admission date of 1/27/20. This record also lists medical diagnosis that include: paralytic gait, anxiety disorder, contracture of the left and right hand and hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side. R25's Quarterly Minimum Data Set, dated [DATE] documents that R25's Brief Interview for Mental Status score is a 9 indicating he has a moderate impairment of cognition. This same document in Section G indicates that R25 requires extensive assistance of two persons for: bed mobility, transfers, toilet use, persona hygiene, and dressing. [...]

Inspectors wroteBased on record review and interview the facility failed to update the comprehensive care plan with new focus areas and interventions for 1 of 15 residents (R47) reviewed for care plans in a sample of 34. The Findings Include: R47's admission record documents an admission date of 1/23/23. This same document includes the following diagnosis: Alzheimer disease, anxiety, and depression. On 9/24/23 a dietary recommendation note for R47 written by V6 (Registered Dietitian) documents r/t (related to) wt (weight loss) and current intakes , rec (recommend) mighty shakes bid (twice daily). R47's current physician order sheet has an order for mighty shakes with meals twice a day with a start date of 9/25/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a residents medication regimen was free from unnecessary medications for one of five residents (R33) reviewed for unnecessary medications in the sample of 34.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from significant medication errors for two of 14 residents (R33, R47) reviewed for medication errors in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to store controlled medications under double locks per current standards of practice for 1 of 4 residents (R29) reviewed for controlled medication storage in the sample of 34. Findings Include: On 10/20/23 at 9:47 AM, observation of the locked medication storage room with V3 (Licensed Practical Nurse) present revealed a refrigerator labeled for medication storage only. This refrigerator was not observed as being locked. Present inside the refrigerator was an open bottle of Lorazepam oral concentrate 2 milligrams / milliliter labeled for R29. V3 confirms that this refrigerator is not kept locked, although the Lorazepam is acknowledged to be stored in this refrigerator. Other medications such as insulin and vaccinations were also noted to be stored in this refrigerator. [...]