Health inspection·September 15, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few to left of midline of forehead that extended into the scalp. There was dried blood noted to the center of the hematoma. There were also sutures present but unable to determine how many due to the dried blood. R1 had yellow, purple and blue bruising extending all the way down her face into her neck. R1 was not interviewable at that time.On [DATE] at 11:58 AM, V10, (Certified Nurse's Aide/CNA) stated on [DATE] while she was assisting R1 to get ready for lunch R1 was lying in bed. V10 stated she had left the mechanical lift outside the door of R1's room until R1 was readied for transfer from bed to wheelchair. V10 stated she left R1's bedside unattended to retrieve the mechanical lift outside R1's door of room. V10 stated when she left R1's bedside unattended R1's bed was in the lowest position and R1's side rails were up, but R1's fall mat was not placed back in the proper position of R1's bedside. V10 stated when she walked out of the room, she then heard V11(CNA) yell for her to get back in the room. V10 stated when she rushed back into R1's room she observed R1 lying on her left side next to her bed with bleeding coming from her head. V10 stated in looking back she believed she did not leave R1 in the safest possible position before leaving the bedside because she did not place R1's fall mat back at side of bed. V10 stated the protocol for getting R1 ready to transfer via use of the mechanical lift is one staff member stays at bedside while the other retrieves the mechanical lift. V10 stated she simply was not thinking, leaving R1 unattended and fall mat removed from bedside while retrieving the mechanical lift. V10 stated she believes R1's fall could have been prevented if the other staff member, V11 had been at bedside to prevent R1 from rolling out of bed, or at the least R1's injuries from the fall could have been less severe if fall mat had been in place according to R1's fall precautions. On [DATE] at 9:52 AM, V11, CNA stated on [DATE] she had initially walked in R1's room by herself to ready R1's roommate for transfer from bed to wheelchair. V11 stated soon after she saw V10 step into the room and go to R1's bedside to assist R1 in getting ready to transfer from bed to wheelchair via mechanical lift; she pulled the privacy curtain between the two residents. V11 stated the next thing she knew, she heard an awful noise and asked V10 if she was ok. V11 stated she didn't get a response and stepped around the curtain to check on V10. V11 stated at that time she observed V10 had left the room and R1 was lying on the floor beside the bed on her left side with active bleeding coming from somewhere on her head. V11 stated immediately after R1's fall she noted R1's fall mat was not in place and R1's bed was not in the lowest position. V11 stated she would describe the bed height at approximately waist height for most people. V11 stated she did know R1 had a history of falls and was at risk for further falls. V11 stated she did not believe the safest practice of having R1's bed in the lowest position and fall mat placed back at bedside was followed for R1's safety. V11 stated she believed R1's injury could have been prevented if V10 had not left R1 unattended or at the least R1's injuries could have been less severe if all fall precautions had been put back into place before V10 left the room. V11 stated she always does R1's transfers and care with a second staff member because she is a two-assist resident.On [DATE] at 4:14 PM, V15 (Medical Doctor/MD) stated R1's injuries could possibly have been less severe if the fall mat had been placed back at bedside before V10 stepped away from the bedside to retrieve the mechanical lift.On [DATE] at 1:08 PM, V14 (CNA) stated the safest way to leave a resident who is at risk for falls is to place all their fall precautions back into place including the fall mat back into correct position at bedside. V14 also stated she believed R1's fall could have been completely prevented if V10 had waited for a second staff member to assist her in getting R1 ready for transfer, or at least R1's injuries could have been less severe if V10 had placed R1's fall mat back into proper position at bedside before stepping out of the room leaving R1 unattended.On [DATE] at 1:22 PM, V12 (CNA) stated the safest way to leave a resident unattended including R1 is to place resident's bed into the lowest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145760 If continuation sheet Page 2 of 3 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 09/15/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete position and put all their fall precautions back into place including their fall mat.On [DATE] at 10:51 AM, V9 (Registered Nurse/RN) stated the safest practice when leaving a resident unattended to retrieve the mechanical lift for transfer is to place all fall precautions back into place including the resident's fall mat if has the mat listed as an intervention. V9 stated regarding R1's fall, they were unsure if it could have been completely prevented but does believe R1's injuries could possibly have been less severe if all fall precautions had been put back into place including her fall mat before V10 had left R1's room.On [DATE] at 2:00 PM, V2 (Director of Nurses/DON) stated she was here on [DATE] and assisted with first aid for R1 after her fall until emergency medical technicians arrived on grounds. V2 stated she believed V10 should have placed R1's fall mat back at bedside before stepping out of the room to retrieve the mechanical lift. V2 stated re-education of all CNA staff regarding transfers and fall prevention/safety was conducted with all CNA staff within twenty-four hours after R1's fall.On [DATE] at 1:16 PM, V1 (Administrator) stated after the fall of R1 re-education on transfers and fall prevention/safety was conducted for all CNA staff within twenty-four hours after R1's fall. V1 stated she was unsure if R1's fall could have been completely prevented or that R1's injuries could have been less severe but did believe V10 should have placed R1's fall mat back at bedside before stepping out of the room to retrieve the mechanical lift.Facility's fall policy revised [DATE] document in part, Purpose: . to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to minimize fall related injuries.Prior to the survey date, the facility took the following actions to correct the noncompliance:1. V1 stated in-servicing on safe transfers using mechanical lifts and placing fall precautions back into place before leaving residents was completed with all CNA's within twenty-four hours of the incident involving R1. V1 stated there was a Quality Assurance and Performance Improvement plan put into place on [DATE]. V1 stated facility monitored safe transfers using mechanical lifts and residents having fall precautions in place over for four days up until [DATE] with a one hundred percent success rate. V1 stated they will monitor over the next quarter using surprise inspections conducted by V1 to make sure mechanical lift transfers are being conducted safely and fall precautions are in place.2. Facility's Quality Assurance and Performance Improvement report dated [DATE] documents a sample of six residents was reviewed from [DATE]-[DATE] for safe transfers using a mechanical lift and fall precautions were in place for those six residents. The report documents the success rate as one hundred percent at that time. The same report documents these two aspects will be monitored using a larger sample size over the next quarter and monitored. 3. Inservice documentation for CNA staff with a start date of [DATE] with a Topic/Subject: Transferring with mechanical lift/fall intervention, safety shows all CNA staff signed off on completing the training. Included with the documentation was a document titled Transferring with Mechanical Lift Education and the facility's policy titled Using Mechanical Lift dated [DATE] indicating CNA staff were trained on safe transfers of residents using mechanical lifts and importance of fall precautions. Event ID: Facility ID: 145760 If continuation sheet Page 3 of 3