Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Robinson Rehab And Nursing during CMS and state inspections, most recent first.
Dish machine and 3-compartment sink sanitizer levels were not effectively maintained. A cook tested the dish machine and sanitizer bucket and found 0 ppm readings, while the log had been completed as if the sanitizer level was 50 ppm for every meal. Later, the dish machine tested at 200 ppm chlorine, which was above the facility’s stated range, and the sanitizer bucket again showed no sanitizer. Facility policy required dish machine sanitizer to be 50-100 ppm chlorine and the 3-compartment sink sanitizer to be 200 ppm.
Infection control practices were not followed for residents requiring transmission-based precautions and for shared glucometer use. Two residents with orders for enhanced barrier precautions had no isolation signs or PPE stations outside their rooms during observation, and staff stated the precautions were missed or not verified after admission. In another observation, an RN used the same glucometer and supplies for two residents without disinfecting the machine between uses, despite policy requiring cleaning after every use.
A resident with dementia, muscle weakness, and a history of falls was left unattended in bed without required fall precautions in place while a CNA left to retrieve a mechanical lift. The resident fell, sustaining a knee fracture, scalp hematoma, and subarachnoid hemorrhage. Staff interviews confirmed that established protocols and care plan interventions, including the use of a fall mat and two-person assistance, were not followed at the time of the incident.
A resident who was dependent on staff for toileting due to multiple medical conditions experienced repeated incontinence episodes after call lights went unanswered for extended periods, particularly during night shifts and weekends when CNA staffing was low. The resident and family reported feelings of humiliation and frustration, and staff interviews confirmed that short staffing made it difficult to meet residents' needs in a timely manner.
Multiple residents requiring significant assistance with ADLs experienced prolonged delays in care, especially during nights and weekends, due to insufficient CNA staffing. Staff and nurse interviews confirmed that scheduled absences were not consistently covered, leading to only three CNAs caring for 60 residents, many of whom needed two-person assistance. Facility records and schedules supported these findings, demonstrating a failure to provide adequate staff to meet resident needs.
The facility failed to maintain air conditioning, resulting in uncomfortably high indoor temperatures for all residents over several days. Staff and residents reported widespread discomfort, and temperature logs confirmed readings above recommended levels. Despite using fans and offering hydration, the measures were insufficient, and delays in HVAC repair prolonged the issue, affecting residents including those with chronic health conditions.
The facility failed to complete quarterly MDS assessments for nine residents within the required time frames. The MDS Coordinator was unable to submit the assessments on time due to being pulled to cover shifts, resulting in non-compliance with CMS guidelines.
The facility failed to complete comprehensive assessments for two residents within the required time frames. For one resident, the last comprehensive MDS assessment was completed over a year ago, and the current assessment was not completed within 14 days of the ARD. Similarly, another resident's comprehensive assessment was delayed beyond the required period. The MDS Coordinator confirmed the delay was due to being pulled to cover shifts, causing a backlog in assessments.
A resident with protein-calorie malnutrition and dysphagia did not receive the prescribed high protein pudding with meals, as observed on two occasions. The Speech Language Pathologist confirmed the dietary requirement, while the Dietary Manager acknowledged the oversight. The facility administrator expected adherence to physician orders for nutritional supplements.
A resident with a history of encephalopathy, hemiplegia, and dysphagia was not provided with the necessary adaptive utensils, specifically nosey cups, as prescribed by their physician. Despite the care plan indicating the need for these cups, the resident was observed using regular cups with straws during meals. The facility lacked a policy on adaptive utensils, contributing to the oversight.
The facility failed to maintain aseptic technique during urinary catheter care for a resident with severe cognitive impairment, as a CNA did not change gloves or perform hand hygiene. Additionally, a physician did not use PPE when entering a COVID-positive resident's room, contrary to CDC guidelines and facility policy.
Dish machine and sink sanitizer levels not maintained
Penalty
Summary
The facility failed to ensure that the dish machine and the 3-compartment sink were effectively sanitizing dishes and stationary equipment. During an initial kitchen observation, the cook tested the dish machine sanitizer with a quaternary strip and then with a chlorine strip, and both readings were 0 ppm. A sanitizer bucket was also tested with a quaternary strip and read 0 ppm. The dishwasher temperature log for November 2025 showed the sanitizer level for the dish machine should be 50 ppm chlorine, yet the log had been completed for the breakfast shift by the cook and documented 50 ppm for every breakfast, lunch, and supper entry for the month. When asked about the readings, the cook stated the sanitizer level was always ok and did not indicate that the level had been checked that morning. The dietary manager stated the facility had recently switched companies that deliver and maintain the dish machine and that the sanitizer bucket for stationary equipment was supplied by the same company through a premixing system at the 3-compartment sink. She stated staff were expected to check sanitizer levels before each meal and when fresh buckets were made. On a later observation, the cook stated the dish machine sanitizer had been fixed, but the chlorine strip reading was 200 ppm, which is above the recommended level in the facility policy. At the same time, the sanitizer bucket tested with a quaternary strip showed no sanitizer, and a fresh bucket mixed by the cook again did not register sanitizer. Facility policies dated 12/30/24 stated dish machines using bleach are to be tested prior to dishes entering the machine with a correct solution of 50-100 ppm chlorine, and hand-washed pots and pans in the 3-compartment sink require a sanitizer solution of 200 ppm.
Infection Control Practices Not Followed for Isolation Precautions and Glucometer Use
Penalty
Summary
The facility failed to follow infection control policy and procedure for 4 of 16 residents reviewed for infection control. R54 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, polyosteoarthritis, neuromuscular dysfunction of the bladder, major depressive disorder, hypotension, and acute kidney failure, and had an order for a monthly suprapubic catheter change and enhanced barrier precautions. R57 was admitted with diagnoses including an unspecified fracture of the third lumbar vertebra, iron deficiency anemia, acute posthemorrhagic anemia, type 2 diabetes mellitus, hypertension, atrial fibrillation, postlaminectomy syndrome, and discitis, and had an order for daily daptomycin intravenous therapy and enhanced barrier precautions. During the initial tour, R54 and R57 had no isolation precaution signs outside their rooms and no isolation station for PPE outside their rooms. The CMS 802 matrix did not show transmission-based precautions checked for either resident. The infection preventionist nurse stated she was not sure why the precautions were not on the doors and said they should have been in place immediately. The administrator stated the facility was auditing to ensure all residents who require isolation precautions are on them. Later observations showed isolation signs and PPE carts outside both rooms. The infection preventionist nurse stated she tells nursing staff when a resident needs isolation precautions, but she does not double check residents after admission to ensure precautions are in place. She also stated she was certain R54 had isolation signs on the door previously and was not sure how or when they were removed, and that R57’s precautions for the mid-line were missed. The DON stated it was her expectation that the infection preventionist nurse communicate and follow up on isolation precautions, and that there was no reason R54 and R57 were not on precautions. In a separate observation, a nurse performed blood glucose checks on R59 and then used the same glucometer and supplies for R13 without cleaning the machine between residents, despite the facility policy requiring shared glucometers to be wiped with disinfectant and allowed to air dry after every use and between each resident.
Failure to Implement Fall Precautions and Supervision Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and implement effective interventions to prevent a fall for a resident with significant risk factors. The resident had a history of dementia, muscle weakness, unsteady gait, and was dependent on staff for all activities of daily living except eating. The care plan included interventions such as keeping non-skid footwear on, ensuring the call light was within reach, placing a fall mat beside the bed, and requiring a mechanical lift with two staff for transfers. Despite these documented interventions, the resident was left unattended at the bedside without the fall mat in place while a staff member left the room to retrieve the mechanical lift. During the incident, one CNA left the resident alone in bed, with the bed in a low position and side rails up, but without the fall mat in place as required by the care plan. The protocol for transferring the resident called for one staff member to remain at the bedside while the other retrieved the lift, but this was not followed. Another CNA, who was in the room separated by a privacy curtain, discovered the resident on the floor with active bleeding from the head. The resident sustained a left knee fracture, a large scalp hematoma, and a right parietal subarachnoid hemorrhage as a result of the fall. Multiple staff interviews confirmed that the safest practice was not followed, as the resident was left unattended and fall precautions were not in place. Staff acknowledged that the fall mat was not positioned correctly and that the resident should not have been left alone, especially given her high risk for falls and cognitive impairment. The facility's fall policy required identification of at-risk residents and implementation of appropriate interventions, but these were not adhered to at the time of the incident.
Delayed Call Light Response Leads to Resident Incontinence and Loss of Dignity
Penalty
Summary
A deficiency occurred when the facility failed to respond to a resident's requests for assistance in a timely manner, resulting in the resident experiencing incontinence episodes. The resident, who was cognitively intact and dependent on staff for toileting and other activities of daily living due to multiple medical conditions including morbid obesity, spinal stenosis, and muscle weakness, reported having to urinate on herself on several occasions. These incidents were specifically noted to occur during night shifts and weekends when staffing levels were lower than during the day. The resident expressed feelings of discomfort, anxiety, humiliation, and embarrassment as a result of these events. Documentation from resident council meetings and grievance forms indicated ongoing concerns about insufficient CNA staffing at night, with repeated complaints from the resident and her family about delayed call light responses and unmet needs such as assistance with toileting and obtaining ice water. The resident and her family reported multiple instances where the call light was left unanswered for extended periods, sometimes over an hour, leading to incontinence. Staff interviews corroborated these accounts, with CNAs and nurses acknowledging that short staffing, particularly on weekends and during busy evening hours, made it difficult to respond promptly to call lights, especially for residents requiring two-person assistance. Facility leadership and staff confirmed that there were frequent staffing shortages, especially when scheduled CNAs called in and were not replaced. The facility's census showed a significant number of residents requiring two-person assistance, further straining available staff. Staff reported that management was aware of the issue, and that the problem was exacerbated by additional duties such as laundry falling to night shift staff. The facility's own policy emphasized the right of residents to be treated with respect and dignity, which was not upheld in these instances.
Insufficient Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were scheduled and available to meet the needs of all residents, as evidenced by multiple resident and staff interviews, record reviews, and staffing schedules. Several residents, all of whom were cognitively intact and required significant assistance with activities of daily living (ADLs) such as toileting, bathing, dressing, and transfers, reported frequent and prolonged delays in having their call lights answered, particularly during night shifts and weekends. Residents described waiting up to an hour for assistance, especially when two-person assistance was required, and noted that staffing levels were noticeably lower on weekends compared to weekdays. Staff interviews corroborated these concerns, with CNAs and nurses reporting that there were often only three CNAs in the building during night shifts, despite a significant number of residents requiring two-person assistance. Staff also indicated that when scheduled CNAs called in absent, they were not consistently replaced, resulting in even fewer staff available to provide care. The Director of Nursing acknowledged that the facility ideally needed four CNAs per night shift but confirmed that this was not always achieved, particularly on weekends. Staff described being unable to complete all required care tasks, such as showers and timely response to call lights, due to insufficient staffing. Review of staffing schedules and facility census confirmed that on several documented dates, only three CNAs were scheduled to care for 60 residents, 35 of whom required two-person assistance for care and transfers. The facility's own policy required sufficient staff to assure resident safety and maintain the highest practicable well-being, but the documented staffing patterns did not meet these needs. The deficiency was further substantiated by the facility's own records and the consistent reports from both residents and staff regarding inadequate staffing and delayed care.
Failure to Maintain Safe and Comfortable Temperatures During HVAC Outage
Penalty
Summary
The facility failed to maintain air conditioning equipment and provide comfortable temperatures for all 21 residents reviewed, resulting in indoor temperatures consistently exceeding recommended comfort levels. Observations revealed that fans were placed in resident rooms and hallways, lights were turned off in common areas to reduce heat, and activities were postponed due to high temperatures. Multiple staff and residents reported that the building was uncomfortably hot, with some residents describing the environment as 'miserable' and staff noting that complaints about the heat were widespread. Thermostat and thermometer readings taken by surveyors and facility logs confirmed that temperatures in various areas of the facility, particularly the east hall and dining room, ranged from 78 to 84 degrees Fahrenheit over several days, with some areas exceeding 82 degrees. The deficiency was further compounded by delays in repairing the air conditioning system. The administrator and maintenance staff described a sequence of events where the initial HVAC company failed to respond promptly, resulting in prolonged periods without adequate cooling. During this time, the facility attempted to mitigate the heat by using fans, shutting blinds, offering hydration stations, and encouraging residents to stay in their rooms or in smaller activity groups. Despite these efforts, the temperature logs and staff interviews indicated that the measures were insufficient to maintain a comfortable environment, especially during a period of extreme outdoor heat and humidity, as documented by historical weather data. Residents affected by the deficiency included those who were cognitively intact and able to articulate their discomfort, as well as those with chronic medical conditions that increased their vulnerability to heat-related illnesses. The facility's own documentation acknowledged the risks associated with extreme heat for elderly residents and those with cardiopulmonary conditions, high blood pressure, or mental illness. However, the lack of timely and effective action to restore air conditioning resulted in sustained exposure to uncomfortable and potentially unsafe temperatures for all residents on the east hall.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly assessments for nine residents were completed within the required time frames. The residents involved were R13, R16, R25, R27, R47, R48, R49, R52, and R54, all of whom had their quarterly Minimum Data Set (MDS) assessments initiated but not completed or submitted within the mandated 92 days between assessments. Additionally, the assessments were not completed within 14 days after the Assessment Reference Date (ARD) as required by the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines. The MDS Coordinator, identified as V3, confirmed that the delay in submitting the assessments was due to being pulled to cover shifts on the floor because of staff illness and call-ins. This resulted in the MDS assessments being initiated in July but not completed by the time of the review in August. The report highlights that the facility did not adhere to the CMS RAI Version 3.0 Manual Chapter 2 requirements, which stipulate that there should be no more than 92 days between OBRA assessments and that the MDS completion date must be no later than 14 days from the ARD.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for two residents, R12 and R44, within the required time frames as mandated by the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual. For resident R12, the last comprehensive Minimum Data Set (MDS) assessment was completed with an Assessment Reference Date (ARD) of 7/4/23, and the most recent quarterly MDS assessment had an ARD of 4/7/24. The current comprehensive MDS assessment was initiated with an ARD of 7/2/24 but had not been completed or submitted by the review date of 08/16/24. This resulted in more than 92 days between quarterly assessments and more than 366 days between comprehensive assessments, with the comprehensive assessment not completed within 14 days after the ARD. Similarly, for resident R44, the previous comprehensive MDS assessment had an ARD of 7/12/23, and the most recent quarterly MDS assessment had an ARD of 4/7/24. The current comprehensive MDS assessment was initiated with an ARD of 7/6/24 but also lacked a completion date by 08/16/24. This led to more than 92 days between quarterly assessments and more than 366 days between comprehensive assessments, with the comprehensive assessment not completed within 14 days after the ARD. The MDS Coordinator, V3, confirmed that the delay in completing these assessments was due to being pulled to cover shifts because of staff illness and call-ins, which caused a backlog in completing the assessments.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for a resident identified as R47, who was diagnosed with unspecified protein-calorie malnutrition and dysphagia. R47's physician order summary dated May 13, 2024, included a prescription for high protein pudding. However, during observations on August 13 and 14, 2024, R47 was served meals that did not include the prescribed high protein pudding. The meals consisted of a regular mechanical diet, which included items such as ground pulled pork, creamed corn, and frosted cake, but lacked the high protein pudding that was ordered to address R47's nutritional needs. Interviews with facility staff revealed a lack of awareness and oversight regarding R47's dietary requirements. The Speech Language Pathologist (SLP) confirmed that R47 should have received high protein pudding with lunch and supper meals. The Certified Nurse Assistant (CNA) was unsure of R47's dietary needs and indicated she would check with dietary staff. The Dietary Manager acknowledged the oversight and confirmed that R47 should have received the high protein pudding, attributing the failure to a dietary oversight. The facility administrator expressed an expectation that dietary staff should follow physician orders and provide the necessary nutritional supplements.
Failure to Provide Adaptive Utensils for Resident
Penalty
Summary
The facility failed to provide adaptive utensils for a resident, identified as R21, who required them for eating and drinking. R21 had a history of encephalopathy, hemiplegia, hemiparesis, cerebral infarction, and dysphagia, which necessitated the use of adaptive equipment such as nosey cups for liquids. Despite the physician's orders and care plan specifying the need for these cups, observations during lunch on two consecutive days revealed that R21 was served beverages in regular cups with straws instead of the prescribed nosey cups. Interviews with the resident and staff confirmed the absence of the adaptive equipment, with the Dietary Manager admitting that the cups might have been discarded. The deficiency was further highlighted by the lack of a facility policy regarding the provision of adaptive utensils, as stated by the Administrator. Although the facility's staff were expected to follow physician orders, the absence of a formal policy contributed to the oversight. The Administrator later acknowledged the issue and mentioned that new nosey cups had been ordered and some were found in the resident's room, but this was after the deficiency had been identified.
Infection Control Deficiencies in Aseptic Technique and PPE Use
Penalty
Summary
The facility failed to maintain aseptic technique during urinary catheter care for a resident with severe cognitive impairment and multiple medical conditions, including multiple sclerosis and neurogenic bladder. A Certified Nurse Assistant (CNA) did not change gloves or perform hand hygiene after removing a soiled brief containing fecal matter and before continuing with perineal care. The CNA admitted to not changing gloves due to nervousness and lack of recent experience. The Director of Nursing and Administrator both stated that they expected staff to follow facility policies, which require glove changes and hand hygiene during such procedures. Additionally, the facility did not implement proper transmission-based precautions for a resident with a positive coronavirus test. A physician entered the resident's room without wearing personal protective equipment (PPE) and left the door open, despite the presence of isolation droplet precaution signs and available PPE outside the room. The physician expressed a belief that isolation was unnecessary for COVID-19, contrary to CDC guidelines and facility policy. The Director of Nursing and Administrator confirmed that the physician had been educated on the need for PPE in COVID-positive rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Robinson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Ridgeview | 9.3 mi | ★★★★★ | 26 | 0 |
| Waters Of Sullivan Nursing Facility, The | 18 mi | ★★★★★ | 10 | 0 |
| Oak Village | 18.4 mi | ★★★★★ | 15 | 0 |
| Envive Of Sullivan | 18.7 mi | ★★★★★ | 3 | 0 |
| The Haven Of Bridgeport | 21.1 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.