Robinson Rehab: Staffing Failures Left Resident Incontinent - IL
The resident, identified in inspection records only as R1, lived on a hall with 27 residents during the weekend of August 23 and 24, 2025. Fifteen of those residents required two staff members to transfer or provide care. Ten more needed at least one. On that weekend, one certified nursing assistant and one nurse covered the entire hall.
The CNA who worked that weekend told inspectors on August 29 that she knew she hadn't reached R1 in time. "If I would have been able to get to R1 in time she would not have been incontinent," she said. She described the evening routine, moving residents out of the dining room, changing those who were wet, helping residents who wanted to lie down, and answering call lights, all at once with too few hands. For residents who need two staff to move, she said the wait can easily stretch to an hour.
"I do not do as well as I could because it is impossible," she told inspectors.
The LPN who was R1's nurse that weekend said she didn't learn what had happened until later in the shift, when R1 told her the call light had been on for over an hour. The nurse said one CNA and one nurse is not enough for 30 residents. She said the following Saturday, August 30, a CNA called in sick and the on-call nurse never found coverage and never came in to help.
"It seems every weekend they are short staffed," the LPN said. "All the residents cannot receive the care they need with the current staffing they have."
The CNA told inspectors that management already knew. Night shift staff had complained. They were told to ask other CNAs or the nurse for help. The CNA said all the staff, including the nurses, were already busy. She also mentioned that the weekend laundry worker had recently quit, so night shift staff were handling laundry on top of everything else.
R1 is normally continent. She wasn't that weekend because 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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 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, lived on a hall with 27 residents during the weekend of August 23 and 24, 2025.
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.