Pinckneyville Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was provided timely for 1 of 1 (R13) resident reviewed for dignity in the sample of 28. Findings Include: R13's admission Record with a print date of 03/25/2026 documents R13 was admitted to the facility on [DATE] with diagnoses that include spastic hemiplegia, dementia, lack of coordination, muscle weakness, and history of traumatic brain injury. R13's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 07, indicating a severe cognitive deficit. This same MDS documents R13 is dependent on staff for toileting. R13's current Care Plan documents a Focus area of Self-care deficit r/t (related to) Seizures, Hemiplegia, lack of coordination. Date Initiated: 4/5/2025. This Focus area includes the interventions of, Assist with toileting and showers/bath. [...]

Inspectors wroteBased on Interview, record review, and observation the facility failed to properly check gastrostomy tube placement per professional standards of practice for 1 of 1 (R21) resident reviewed for tube feeding in a sample of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms for 4 of 4 residents (R12, R15, R19, and R20) reviewed for room size in a sample of 28.

Inspectors wroteBased on interview and record review the facility failed to initiate the process to timely obtain a prescription medication for 1 of 3 residents (R1) reviewed for medications in the sample of 7. This past noncompliance occurred from 7/27/25 and 7/28/25.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse for 8 consecutive hours per day seven days per week. This failure has the potential to affect all 42 residents living in the facility. Findings Include: On 04/10/25 at 9:57AM V6 (Licensed Practical Nurse/LPN) stated that most of the time the facility does have a Registered Nurse for 8 consecutive hours a day seven days a week. V6 stated that V2 (Director of Nursing/DON) usually works Monday-Friday, and he covers the Registered Nurse coverage during the week. V6 stated that V4 (Registered Nurse/RN) works every other Saturday on the floor. V6 stated that she doesn't think that they have Registered Nurse coverage on Sunday's. On 04/10/25 at 11:40AM V7 (LPN) stated that the facility does not have Registered Nurse coverage 8 consecutive hours a day seven days a week. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms for 4 of 4 residents (R5, R9, R31, R35) reviewed for room size in a sample of 32 .

Inspectors wroteBased on interviews, observations, and record review the facility failed to implement surveillance measures to detect, treat, and prevent the spread of potential scabies infestation for 7 of 9 residents (R1, R2, R3, R4, R5, R6, and R7) reviewed for infection control in a sample of 9. This failure resulted in R1 experiencing intense itching for over 1 month resulting in signs and symptoms of distress of crying, facial grimacing, and experiencing a loss of appetite. This failure has the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to follow physician's orders for 1 of 7 residents (R1) reviewed for quality of care in a sample of 9.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents were free from peer to peer sexual abuse by (R1) for 3 of 11 residents (R2, R3, R7) reviewed for peer to peer sexual abuse in a sample of 11. This failure resulted in R2, R3, and R7, all of whom are cognitively impaired and incapable of giving informed consent to sexual activity, witnessing masturbation, being touched on the breasts and genitals, and having unsolicited sexual comments directed toward them. These actions would cause a reasonable person to experience feelings of fear, embarrassment, anger, and shame. The Immediate Jeopardy began on 9/23/24 when R1 touched R2's breast, and a plan for effective supervision and monitoring of R1's behavior was not implemented. R1 subsequently went on to sexually abuse R3, and R7. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representatives of peer to peer sexual abuse for two of 11 residents (R3, R7) reviewed for representative notification in the sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to report peer to peer sexual abuse to the Administrator for three residents (R1, R3, R7) of eleven residents reviewed for abuse in the sample of eleven.

Inspectors wroteBased on interview and record review, the facility failed to provide effective behavior interventions for 1 of 11 residents (R1) reviewed for behaviors in the sample of 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a sufficient amount of staff to ensure residents receive showers, and assistance with care. These failures have the potential to affect all 45 residents living in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide dependent residents timely ADL (Activities of Daily Living) assistance for 5 of 7 residents (R4, R5, R6, R7, R9) reviewed for ADL assistance in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy was maintained during personal care services for 2 of 2 residents (R11 and R40) reviewed for privacy in the sample of 25.

Inspectors wroteBased on interview and record review the facility failed to timely perform quarterly Minimum Data Set (MDS) assessments for one of one resident (R149) reviewed for MDS assessments in a sample of 25.

Inspectors wroteBased on interview, record review and observations, the facility failed to prominently post the daily nurse staffing data which includes the facility's name, date, census and the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This failure has the potential to affect all 47 residents who reside at this facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms. This failure affects four of four residents ( R12, R5, R29 and R45) reviewed for environment in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to keep a resident free of physical restraints for 1 (R1) of 5 residents reviewed for physical restraints in the sample of 9. This failure resulted in R1 being tied down in a wheelchair with a bath blanket for an undisclosed amount of time. An independent reasonable person would respond to being restrained to a wheelchair with feelings of fear, anxiety, frustration, agitation, and humiliation. This past non-compliance occurred between 10/12/23 and 10/13/23.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse immediately to the Administrator for 1 of 3 residents (R1) reviewed for abuse in the sample of 9. This past non-compliance occurred between 10/12/23 and 10/13/23.