Health inspection·September 3, 2025

F 0550 Level of Harm - Actual harm Residents Affected - Few has plenty staff. R1 said on weekends the staff number is much lower than during the week. R1 stated she has complained about staffing in resident council meetings and has even sent a text message to V7 (Assistant Director of Nursing/Licensed Practical Nurse - ADON/LPN) on 08/22/2025 and told her that she has had her call light on for over an hour. R1 stated the staff that work here are really good, there just isn't always enough staff to take care of all the residents. On 08/29/2025 at 11:09 AM, V3 (Family Member) stated that R1 called him about 6 weeks to 2 months ago crying and upset. V3 couldn't recall the exact date, but stated R1 told him her call light had been on for 2 hours and no one was answering. V3 stated he told R1 that if she had an accident that was ok, she couldn't help that no one was answering. V3 said he told R1 if you go in the hallway and have pee on yourself then maybe they will help you. V3 stated he hated to tell R1 that, but he did not know what else to do. V3 stated that he was furious, so he called the facility and sternly told them to go take care of R1. V3 stated the nurse who answered the phone told him if you think you can do it better then you need to come here and help. V3 stated he then got on social media and found V7 (ADON/LPN) and explained to her what happened. V3 stated V7 said she would take care of the problem. V3 stated he had no issues with this until last weekend 08/23/2025 and 08/24/2025. V3 stated on 08/23/2025 around 8:00 PM, R1 called because her call light had been on since she came back from the dining room after supper. V3 stated R1 said she told the staff member pushing her that she needed to use the restroom but R1 ended up having to relieve herself and was incontinent. V3 said R1 didn't say who the staff member was. V3 stated he checked with R1 on 08/24/2025 and R1 had no complaints at that time, but R1 called V3 later that night on 08/24/2025 around 8:30 PM and told V3 that R1's call light had been on for over an hour, and no one had answered it. V3 stated that R1 is very proper and that it is degrading that the facility does not have enough help to the point R1 is having to urinate on herself. V3 stated he told R1 that he will notify the proper people and will get this handled. V3 stated on the weekends, the staffing is much lower than during the week. V3 stated if it is happening to R1 who is alert and with it, it is happening to other residents who cannot speak. On 08/29/2025 at 11:35 AM, V7 (ADON/LPN) stated she was contacted by V3 (Family Member) months ago about an issue and it was addressed. V7 stated that R1 sent her a text and told her R1's call light had been on for over an hour, and no one was answering it. V7 stated that it was between 6:00 and 7:00 PM and that time frame is very busy for the staff. V7 stated as soon as staff was available, they went in the room and took care of R1. V7 stated they try to keep a staff member on the hall during meals, but it is hard to meet all the needs after supper. V7 stated they try to schedule enough staff and sometimes if a call in occurs, it doesn't pan out. On 08/29/2025 at 11:39 AM, V2 (DON) stated when R1 was incontinent a couple months ago, she couldn't remember exactly when but she was aware of it as she was working as a CNA that night. V2 stated she went and toileted/cleaned R1, changed her clothes, and placed her in bed. V2 stated they educate the staff all the time about answering call lights promptly. V2 stated she was not aware of any issues that occurred over the weekend with R1. V2 stated call lights should be answered within 10-15 minutes. V2 stated for the weekend of 08/23/2025 and 08/24/2025, there were 3 or 4 CNA's scheduled to work. V2 stated she thinks that one called in and was not replaced. V2 stated in those situations, they try to have a CNA stay late until around 10 PM and then have a day shift person come in around 2:00 - 04:00 A.M. V2 stated they must have not found someone to come in. V2 stated that ideally, she would like to have 4 CNA's every night, but it does not matter what she thinks staffing should be. V2 stated there are two nurses on night shift. V2 stated there are 35 residents in the facility that require two staff assist. V2 stated that on evening/nights, the toughest time is from 6:00 PM to 10:00 PM. V2 stated they attempt to cover when needed but it doesn't always (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete happen. V2 stated they are attempting to hire more staff and get them trained.On 08/29/2025 at 11:44 AM, V1 (Administrator) stated she was not made aware of the call light concerns regarding R1 on the weekend of 08/23/2025 and 08/24/2025 until now. V1 stated the call light does not have a report that can be viewed to see how long the call light was going off. V1 stated she has never been made aware of any resident complaining about call lights going off for an hour. On 08/29/2025 at 2:04 PM, V12 (CNA) stated at times I feel like we are understaffed. V12 stated it is hard to get to call lights on night shift because there are not a lot of staff working. V12 stated there are a lot of times there are only three CNA's in the building for the entire night. V12 stated lately when there are 4 scheduled and someone calls in, they are not replaced on the schedule. V12 stated she gets the bare basics done for the residents, but there are too many that require two-person assist and they have to wait for up to an hour.On 08/29/2025 at 3:21 PM, V11 (CNA) stated R1 had incontinent episodes over the weekend of 08/23/2025 - 08/24/2024. V11 stated that it is not typical for R1 to be incontinent. V11 stated we cannot get to all the residents after supper in a timely manner. V11 stated it happens more often than not. V11 stated a lot of residents have to wait when they shouldn't. V11 stated the staff try to get everyone out of the dining room, residents changed who are wet, the ones who want laid down, laid down and answer the call lights. V11 stated management is aware of the issues as the night shift staff have complained. V11 stated they are told to ask the other CNA's or the nurse for help. V11 stated that all the staff are busy including the nurses and it is hard to get the call lights answered. V11 stated the staff issues are mostly on the weekends. V11 stated she does not do as well as she could because it is impossible. V11 stated if I would have been able to get to R1 in time she would not have been incontinent. V11 stated if a resident is a two assist, they have to wait until there are two staff available and it can easily take an hour. V11 also stated that the weekend laundry staff recently quit so they have to do the laundry on night shift too.On 09/02/2025 at 2:21 PM, V15 (LPN) stated she was working and was R1's nurse the weekend of 8/23-8/24/25 when R1 had an incontinent episode. V15 stated R1 is normally continent, and she thought it was odd that this happened. V15 stated it wasn't until later in the shift, R1 told her that she was incontinent because the call light was on for over an hour. V15 stated that one nurse and one certified nurse assistant is not enough for the 30 residents that reside on R1's hall. V15 stated this last Saturday 08/30/2025 a CNA called in and the nurse on call (V7) did not find any coverage and did not come in to help. V15 stated it seems every weekend they are short staffed. V15 stated all the residents cannot receive the care they need with the current staffing they have.A facility provided census sheet documented there are 27 residents that reside on R1's hall. Of those 27 residents, V2 indicated by placing a dot beside resident names that there were 15 residents who require the assist of two staff for transfers and care, with R1 being one of those residents. V2 indicated by yellow highlight that 10 residents on that hall require the assist of one staff member for transfers and care. Facility policy titled Facility Resident Rights Policy and Procedure with no date documents under section V. Respect and dignity. Every resident has a right to be treated with respect and dignity. Event ID: Facility ID: 145760 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. This MDS also documented under Functional Goals and Abilities R1 is dependent for toileting hygiene, shower/bathe self, upper body dressing, and putting on/taking off footwear.R1's current Care Plan included a focus area of I currently have an alteration to my ability to care for self and need assistance d/t (due to) Anxiety, Cognitive impairment, Weakness initiated on 1/31/25. Corresponding interventions include: encourage resident to participate to the fullest extent possible with each interaction, encourage resident to use bell to call for assistance, praise all efforts at self care, PT (physical therapy), OT (occupational therapy) and ST (speech therapy) evaluation and treatment. R1 also has a focus area of I am currently able to perform mobility with 2 assist, gait belt and walker initiated on 5/7/25 with corresponding interventions of: encourage (R1) to use bell to call for assistance if needed and monitor/document ability to perform ADLs (activities of daily living).On 08/29/2025 at 10:53 AM, R1 stated she sometimes has trouble getting her call light answered. R1 stated on night shift there is one certified nurse assistant (CNA) per hall. R1 stated on weekends the staff number is much lower than during the week. R1 stated she has complained about staffing in resident council meeting and even sent a text message to V7 (Assistant Director of Nursing/Licensed Practical Nurse - ADON/LPN) on 08/22/2025 telling V7 she had her call light on for over an hour. R1 stated the staff that work there are really good, there's just not enough staff to take care of all the residents.2. R2's admission Record documented an admission date of 10/13/2024 and included diagnoses of iron deficiency anemia, major depressive disorder, anemia, osteoarthritis of knee, morbid obesity, major depressive disorder, anxiety disorder, chronic pain syndrome, essential hypertension, unspecified atrial fibrillation, and unspecified systolic congestive heart failure. R2's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R2 is cognitively intact. The same MDS documented under Functional Abilities and Goals R2 is dependent for toileting hygiene and putting on/taking off footwear. The MDS also documented substantial maximum assist for shower/bathe self and lower body dressing.R2's current Care Plan included a focus area of I currently have an alteration to my ability to care for self and need assistance. The interventions listed are to encourage resident to participate to the fullest extent, encourage resident to use bell for assistance and praise all efforts.On 08/29/2025 at 11:27 AM, R2 stated that staffing on weekends is sparse. R2 stated she has to wait long periods of time on the weekends to get her call light answered. R2 stated the staff are all very helpful and can only do what they can. R2 stated that they do not have enough staff on night shift to take care of everyone.3. R3's admission Record documented an admission date of 12/11/2024 and included diagnoses of aftercare following joint replacement, pain in right knee, difficulty walking, morbid obesity, major depressive disorder, acute kidney failure, sleep apnea, essential hypertension, and chronic obstructive pulmonary disease.R3's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R3 is cognitively intact. This MDS documented under Functional Abilities and Goals R3 requires substantial/maximum (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many assist for toileting, showering, dressing, and putting on/taking off footwear.R3's current Care Plan dated 05/22/2025 documents a focus area of I currently have an alteration in my ability to care for myself and need assistance. Interventions listed include encourage provide range of motion, praise all efforts, and therapy as ordered.On 08/29/2025 at 12:10 PM, R3 stated it takes up to an hour for call lights to be answered on weekends. R3 stated the facility does not have enough staff on nights.4. R4's admission Record documented an admission date of 11/08/2022 and included diagnoses of contracture of the left hip, major depressive disorder, atherosclerosis of native arteries, anemia, morbid obesity, essential hypertension, chronic atrial fibrillation, chronic systolic heart failure, and chronic obstructive pulmonary disease.R4's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R4 is cognitively intact. The MDS under Functional Abilities and Goals documented R4 requires substantial/maximum assist for toileting, shower/bathe self, dressing, and putting on/taking off footwear.R4's current Care Plan with a date of 10/21/2024 included a focus area of I currently have an alteration to my ability to care for self and need assistance. The interventions listed are encourage resident to participate to the fullest extent, encourage resident to use bell for assistance and praise all efforts.On 08/29/2025 at 1:42 PM, R4 stated staffing on the weekends is very slim. R4 stated that staff are running around sweating the entire shift because there are not enough staff. R4 stated that there's one CNA on each hall at nights. R4 stated there is not enough staff to cover the residents needs. R4 stated during the day it only takes 15 minutes or less for call lights to get answered but on evenings and weekends, it is 30 minutes to an hour. R4 stated at supper time, you cannot get a staff member to answer a call light. R4 stated that it is very difficult to get staff to help after supper. On 08/29/2025 at 2:04 PM, V12 (Certified Nurse Assistant/CNA) stated at times I feel like we are understaffed. V12 stated it is really hard to get to call lights on night shift because there are not a lot of staff working. V12 stated there are a lot of times there are only three CNA's in the building for the entire night. V12 stated lately when there are 4 scheduled and someone calls in, they are not replaced on the schedule. V12 stated she gets the bare basics done for the residents, but there are too many that require two-person assist and they have to wait for up to an hour.On 08/29/2025 at 2:11 PM, V2 (Director of Nursing/DON) stated for the weekend of 08/23/2025 and 08/24/2025, there were 3 or 4 CNA's scheduled to work. V2 stated she thinks that one called in and was not replaced. V2 stated in those situations, they try to have a CNA stay late until around 10 PM and then have a day shift CNA come in around 2:00 - 04:00 AM. V2 stated they must have not gotten someone to come in. V2 stated that ideally, she would like to have 4 CNA's every night, but it does not matter what she thinks staffing should be. V2 stated there are 35 residents in the facility that require two staff assist. V2 stated that on evening/nights, the toughest time is from 6:00 PM - 10:00 PM. V2 stated they attempt to cover when needed but it doesn't always happen. V2 stated they are attempting to hire more staff and get them trained.On 08/29/2025 at 3:21 PM, V11 (CNA) stated we cannot get to all the residents after supper in a timely manner. V11 stated it happens more often than not. V11 stated a lot of residents have to wait when they shouldn't. V11 stated the staff try to get everyone out of the dining room, residents changed who are wet, the ones who want laid down, laid down and answer the call lights. V11 stated management is aware of the issues as the night shift staff have complained. V11 stated they are told to ask the other CNA's or the nurse for help. V11 stated that all the staff are busy including the nurses and it is hard to get the call lights answered. V11 stated the staff issues are mostly on the weekends. V11 stated she does not do as well as she could because it is impossible. V11 stated if a resident is a two assist, they have to wait until there are two staff available and it can easily take an hour. V11 also stated that the weekend (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145760 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robinson Rehab and Nursing 600 East Robinwood Drive Robinson, IL 62454 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete laundry staff recently quit so they have to do the laundry on night shift too. V11 stated she cannot even get her showers done when she works.On 09/02/2025 at 2:21 PM, V15 (LPN) stated that one nurse and one certified nurse assistant is not enough for the 30 residents that reside on the R1's hall. V15 stated this last Saturday 08/30/2025, a CNA called in and the nurse on call (V7, ADON/LPN) did not find any coverage and did not come in to help. V15 stated it seems every weekend they are short staffed. V15 stated all the residents cannot receive the care they need with the current staffing they have. The July 2025 Certified Nurse Assistant schedule documented on 07/04, 07/11, 07/18 and 07/19 there were only three certified nurse assistants scheduled to work.The August 2025 Certified Nurse Assistant schedule documented on 08/09, 08/15, 08/23, 08/24 there were only three certified nurse assistants scheduled to work.A facility provided census sheet documented there are 3 halls in the facility, one being East/Far East, one being West, and one being North. This document shows 60 residents reside in the facility, with V2 indicating 35 of those residents require two staff assist for care and transfers by placing a dot beside the resident names. V2 indicated by yellow highlight (without a dot) that 19 residents require the assist of one staff member for care and transfers. The East/Far East Hall denotes 27 residents reside on the hall, with 15 requiring the assist of two staff for transfers and care, and 10 requiring the assist of one staff member for transfers and care. The document shows 18 residents reside of the [NAME] Hall, with 11 requiring the assist of two staff for transfers and care and 4 requiring the assist of one staff for transfers and care. The North Hall notes 16 residents reside on the hall, with 9 residents requiring the assist of two staff for transfers and care and 5 residents requiring the assist of one staff for transfers and care. The facility's policy titled Staffing with a revision date of 02/20/2025 documented under section titled Procedure: The facility will provide sufficient staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident.A facility matrix dated 08/29/2025 documented a total of 60 residents residing at the facility. Event ID: Facility ID: 145760 If continuation sheet Page 6 of 6