Robinson Terrace

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for three of three (3 of 3) medication carts and one of two (1 of 2) medication rooms reviewed. Specifically, (a.) Five (5) bottles of eye drops had no open and or expiration dates; (b.) Five (5) insulin pens had no open dates; (c.) Two (2) vial of insulin and two (2) insulin pens had no open and or expiration dates; (d.) One (1) insulin pen had two open dates; (e.) Two (2) inhalers had no open and or expiration dates; (f.) One (1) bottle of Tuberculin Purified Protein Derivative (a sterile mixture of antigens used in the Mantoux skin test to detect Mycobacterium tuberculosis infection) had no open and or expiration date; [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey, the facility did not ensure that alleged violations involving abuse, were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to officials (including to the State Agency). Additionally, the facility did not ensure a report of the results of all investigations were submitted to the State Agency, within five (5) working days of the incident, in accordance with State law for one (1) (Resident #125) of four (4) residents reviewed for abuse. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for two (2) (Residents #s 4 and 14) of 23 residents reviewed for Care Plans. Specifically, (a) Resident #4 did not have a person-centered care plan for pain, although they were receiving scheduled pain medication and were being monitored for pain, and (b) for Resident #14, a comprehensive care plan for hospice was not developed or implemented when the resident was admitted to hospice care on 12/29/2025. This is evidenced by: [...]

Inspectors wroteBased on the record review and interview conducted during the survey, the facility did not ensure that Resident #123 was free of a significant medication error. Specifically, two (2) prescribed anti-seizure medications, carbamazepine and primidone, were omitted after the resident's readmission from the hospital on [DATE]. The medications resumed after the resident experienced a seizure on 11/21/2022. Resident #123 was admitted to the facility with diagnosis of epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain); Post-polio syndrome (muscle and joint weakness and pain that gets worse over time), and other schizophrenia (a chronic, severe mental disorder characterized by a distorted interpretation of reality, including hallucinations, delusions, and disorganized thinking/behavior). [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility did not ensure that resident menus were followed to meet the resident's' nutritional needs for two (2) (Resident #'s 10 and 11) of four (4) residents reviewed. Specifically, Resident #10 was not served an adequate portion of chicken on their meal tray, and Resident #11, who had a care plan of fluid deficit, did not receive tomato juice as listed on their meal ticket for two (2) observed meals. This is evidenced by: The facility policy titled Dietary Portion Control, revised 9/2025, documented that all foods served would follow standardized recipes and prescribed portion sizes to ensure nutritional adequacy, regulatory compliance, cost control, and resident satisfaction. The procedure included: #1.) standardized recipes: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey and an abbreviated complaint survey, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and/or at an appetizing temperature for two (2) of four (4) meals reviewed. Specifically, appetizing and palatable food was not served during a lunch meal on 2/02/2026, and diluted cranberry juice was served at a lunch meal on 2/10/2026. Additionally, six (6) residents (Residents #'s 10, 11, 36, 88, 96, 110) interviewed stated the food did not taste good. This is evidenced by: The facility policy titled, Dietary Menu Planning Policy, revised on 1/2026, documented menus were planned, reviewed, and approved by a Registered Dietitian to ensure nutritional adequacy, therapeutic accuracy, and resident satisfaction. [...]

Inspectors wroteBased on observation, interviews, and record review during the recertification survey dated 02/21/23 through 03/02/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment for three (3) of 3 resident units and the Lobby. Specifically, wallpaper was ripped and curling at the seams and/or bubbling off the wall on the [NAME] Unit (Unit B), Courtyard Unit (Unit C), Mountainview Unit (Unit M), Lobby, and the corridor outside the Beauty Salon; walls were soiled with dirt and/or damaged with holes, scrapes or [NAME] marks, or had missing coving base on Unit B, Unit C and Unit M; on Unit C, the ceiling was peeling in the bathing suite and the kickplate on the outside wall of the nurse station was attached with duct tape; [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 02/21/23 through 03/02/23, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and three (3) of 3 unit kitchenettes. Specifically, in the main kitchen, the automatic dishwashing machine final rinse was 171 degrees Fahrenheit (F) at 37 pounds per square inch water pressure (psi); the concentration of Quaternary Ammonium Compound (QAC) used in the sanitizing rinse sink was found to be zero (0) parts per million (ppm); food temperature thermometers were not in calibration; food and non-food contact surfaces were not clean and in good repair; and the bulk food containers were not labeled; in the kitchenettes, the cabinets below the sinks were in disrepair, and refrigerators were not clean. [...]

Inspectors wroteBased on record review and interview during the recertification survey on 2/21/2023 through 3/2/2023, the facility did not ensure development and implementation of comprehensive person-centered care plans for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 (Resident #s 55, 73, 86, 96, and #100) of 23 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #55, the facility did not ensure the CCP for Actual Alteration in skin integrity included resident specific goals and interventions and did not address compliance with positioning; for Resident #73, the facility did not ensure a CCP was developed to address the resident's pain; [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not esure that resident assessments accurately reflected the resident's status for 8 (Resident #'s 10, 43, 57, 70, 74, 85, 96, and #109) of 23 resident assessments reviewed. Specifically, for Resident #10, the facility did not ensure the Minimum Data Set (MDS) accurately reflected the resident's status related to pain management, for Resident #43, the facility did not ensure the Minimum Data Set (MDS) accurately documented the resident had a severe hearing impairment and did not utilize a hearing aid; for Resident #57, the facility did not ensure the MDS accurately reflected the resident was receiving dialysis care and services; for Resident #70, the facility did not ensure the MDS accurately reflected the resident had a fall with a major injury; [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 9 (Resident #'s 10, 57, 74, 75, 85, 100, 103, 104 and #313) of 23 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #10, the facility did not ensure the CCP included resident specific and non-pharmacological interventions to address the resident's pain; for Resident #'s 100 and 104, did not ensure nutrition CCP's included resident specific information or interventions; [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure (i) A resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and (ii) A resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #109) of 3 residents reviewed for pressures ulcers. Specifically, for Resident #109, the facility did not ensure professional standards of practice for infection control were followed during a pressure ulcer dressing change; [...]

Inspectors wroteBased on record review and interviews during a recertification survey the facility did not ensure that it maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #75) of five residents reviewed for nutrition. Specifically for Resident #75, the facility did not identify and address an ongoing weight loss, and the Medical Doctor (MD) was informed of the resident's weight loss. This is evidenced by: Resident #75: The resident was admitted to the nursing home with diagnoses of dementia, left femur fracture and insomnia. The Minimum Data Set (MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. [...]

Inspectors wroteBased on record review, and interviews during a recertification survey the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (Resident #57) of one resident reviewed for dialysis. Specifically, for Resident #57, the facility did not consistently provide ongoing monitoring for complications before and after dialysis treatments provided at a certified dialysis facility and did not consistently review the resident's dialysis communication book to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This is evidenced by: Resident #57: [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure laboratory services were obtained or provided timely to meet resident needs for 1 (Resident #57) of 2 residents reviewed for laboratory services. Specifically, for Resident #57, laboratory tests ordered by the physician were not completed according to the physician order. This was evidenced by: Resident #57: The resident was admitted to the facility with the diagnoses of end stage renal disease (ESRD), diabetes, and hyperlipidemia. The Minimum Data Set (MDS - an assessment tool) dated 8/31/2020 documented the resident was cognitively intact, could understand others and could make self understood. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during a recertification survey the facility did not ensure medical records were maintained in accordance with accepted professional standards of practice on one (Mountainside Unit) of three units. Specifically, the facility did not ensure 3 (Resident #'s 29, 43, and #109) of 9 resident records reviewed for accurate documentation were accurately documented; for Resident #29, the facility did not ensure a physician order for Norco Tablet 5-325 mg (Hydrocodone- Acetaminophen-narcotic pain medication) was discontinued when the order for Norco was renewed resulting in 2 orders for Norco listed on the Medication Administration Record (MAR); [...]