Robin Run Health Center

In the surveyor’s words

From the most serious findings on record at Robin Run Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 1, 2026

  Based on observation and interview, the facility failed to ensure a resident with a full code and a change in condition was closely monitored and treated timely; and failed to ensure effective communication with hospice resulting in the resident having a delay in treatment and death for 1 of 3 residents reviewed for death (Resident B). The Immediate Jeopardy began [DATE], when a resident with a full code who had been alert and participating in her care, had an overall change of condition, the staff were unable to obtain labs, and the family had requested the resident be sent to the ER. The facility called Hospice and Hospice convinced the family to not send the resident to the ER. No Hospice assessment, admission, or contract had been obtained at that time. […]

• Immediate jeopardy, isolatedF684Apr 1, 2026

  Based on record review and interview, the facility failed to ensure physician's orders were obtained for and treatments were provided for an enterocutaneous fistula (an abnormal passage between the bowel and the skin, allowing intestinal contents to leak onto the abdominal wall) while a resident awaited surgical intervention for the area for 1 of 3 residents reviewed for quality of care (Resident B). Findings include:Resident B's record was reviewed on 3/31/26 at 10:31 a.m. Census information indicated the resident was admitted to the facility on [DATE] and hospitalized on [DATE]. Diagnoses on the resident's profile included, but were not limited to, fistula of the intestine. […]

• Actual harm, isolatedF600Jun 1, 2026

  Based on record review and interview, the facility failed to protect a resident's right to be free from physical abuse and mental abuse by a staff member when the staff member roughly provided resident care and left the resident exposed without clothes while a non-caregiver observed via a video phone call without the resident's knowledge for 1 of 3 residents reviewed for abuse (Resident E). Using the reasonable person concept, it is likely the deficient practice would lead to psychosocial distress, anxiety, and/or fear. […]

• Actual harm, isolatedF686Jun 1, 2026

  Based on observations, interviews, and record reviews, the facility failed to implement timely interventions and treatments for residents who had pressure ulcers resulting in harm when those pressure ulcers worsened as a result of the lack of implementing interventions and treatments for 3 of 4 residents reviewed for pressure ulcers (Residents Q, L, and D). Findings include:1. On 6/1/26, at 10:15 a.m., the wife of Resident Q indicated she was concerned regarding Resident Q's care. She indicated that Resident Q was admitted to the facility, following a hospital stay, on 5/8/26 with intact skin. She indicated Resident Q had never had a pressure ulcer prior to his stay at the facility. […]

• Actual harm, isolatedF686Apr 1, 2026

  Based on record review, interview, and observations, the facility failed to implement interventions to treat pressure ulcers and failed prevent pressure to residents' bony prominences for 2 of 3 resident's reviewed (Resident H and G).Findings include:1. On 3/31/26 at 11:40 a.m. Resident H was not in her room. She had a regular mattress. A heel protector sat next to her bed on a fall mat. On 3/31/25 at 11:52 a.m., Resident H was observed sitting in her wheelchair, head down with her eyes closed in the Activity room. She was dressed appropriately with non-skid socks on, with her feet resting on her foot pedals. Staff assisted resident back to her room. Her heels were observed. The right heel skin was intact. […]