Robinson Rehab: Staffing Failures Left Resident Incontinent - IL
The resident, identified in inspection records only as R1, is not typically incontinent. Her nurse that weekend, an LPN identified as V15, said she didn't learn what had happened until later in the shift, when R1 told her herself. "It wasn't until later in the shift," V15 told inspectors on September 2, "R1 told her that she was incontinent because the call light was on for over an hour."
R1 lives on a hall with 27 residents. Fifteen of them, including R1, require two staff members to assist with transfers and care. Ten more require at least one. On the weekend this happened, V15 said one nurse and one certified nursing assistant were covering that entire hall.
That is not unusual, according to the staff who work there.
A CNA identified as V11 told inspectors that what happened to R1 reflects something broader. "It happens more often than not," she said. After supper, staff scramble to move residents out of the dining room, change those who are wet, help those who want to lie down, and answer call lights, all at the same time. For residents who need two people to move them, the wait can stretch to an hour. "If I would have been able to get to R1 in time she would not have been incontinent," V11 said. "It is impossible."
V11 also mentioned that the weekend laundry staff had recently quit. Night shift CNAs were picking up laundry duties on top of everything else.
Another CNA, V12, described night shifts where only three aides are working for the entire building. When a fourth person is scheduled and calls in, V12 said, they are not replaced. "I get the bare basics done for the residents," V12 told inspectors, "but there are too many that require two-person assist and they have to wait for up to an hour."
The problems are concentrated on nights and weekends. V15 said that the Saturday after R1's incident, August 30, a CNA called in sick and the on-call nurse, V7, neither found coverage nor came in to help. "It seems every weekend they are short staffed," V15 said. "All the residents cannot receive the care they need with the current staffing they have."
Management was aware. V11 said night shift staff had complained to management and were told to ask other CNAs or the nurse for help. V11 noted that all of them, nurses included, were already busy.
The administrator, identified as V1, told inspectors on August 29 that she had not been informed about R1's call light situation until the inspection itself. She said the call light system has no report function that would let her see how long a light had been going off. She said she had never been made aware of any resident complaining about a call light going unanswered for an hour.
The director of nursing, V2, acknowledged the staffing problems and said the facility was attempting to hire more staff and get them trained.
The inspection was conducted as a complaint investigation and was completed September 3, 2025. Inspectors cited the facility for failing to treat residents with dignity and respect, a deficiency classified as causing actual harm.
R1 told her nurse what happened to her. She had been continent. She had her call light on. She waited, and waited, and nobody came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robinson Rehab and Nursing from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
ROBINSON REHAB AND NURSING in ROBINSON, IL was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records only as R1, is not typically incontinent.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.