Inspection·April 20, 2023

F 0689 encountered. R1 will have front anti-tippers applied to her wheelchair. Level of Harm - Actual harm R1's emergency room Physician Chart, dated 3/31/23, documents under additional information that a medical emergency called patient (PT) on ground outside fell out of wheelchair (W/C) while being pushed into hospital for appointment. The emergency room Physician chart further documents under Physical Exam that R1 had a laceration on left (side) of forehead measuring 4.5cm (centimeters). R1 also had left eye lid ecchymosis, left infraorbital skin tear as well as some left forehead skin tears. The same document under Procedure that a repair of the laceration was completed using a one-layer closure. Length of the laceration repair was 4.5 cm, was closed with 4-0 nylon (sutures). Residents Affected - Few R1's Care Plan documents a Care Plan category of fall and a history of falling with a start date of 12/2/22 with documented interventions of remind to ask staff for assistance with ambulation, assist of 1 staff member for ambulation, and monitor for changes in condition that may warrant increased supervision/assistance, notify physician. R1's Care Plan documents an intervention dated 1/19/23 of resident wheelchair will be placed close to resident as a visual clue to have resident ask for assistance. R1's Care Plan also documents a Care Plan category of Fall from W/C while being transported to an appointment with a start date of 3/31/23. Interventions documented include monitor bruising on R1's face and report to physician as needed, when transporting resident pull resident from behind when going over a bump, in-service to train staff on proper transportation of resident. The same care plan notes an intervention with a start date of 4/1/23 for foot pedals to be used at all times during transport. On 4/18/23 at 9:45am, V1 (Administrator) said she completed the investigation on the incident on 3/31/23 involving R1 falling from her wheelchair when out of the facility going to an appointment. V1 said that R1 had an appointment at the hospital for a Doppler study. V3 (CNA/Certified Nurse Assistant) took her to the appointment. V1 said that V3 was pushing R1 in the wheelchair and hit the ADA (Americans with Disabilities Act) truncated surface tile and the wheels stopped causing R1 to fall out of the wheelchair. V1 said that R1's family was there when the incident occurred but is not sure if he witnessed the incident or not. V1 said that V3 was very upset over the incident. V1 said that R1 was taken into the emergency room at the hospital and received stitches and also had some bruising to her face. V1 said she is not sure if V3 had the footrests on the wheelchair or not. On 4/18/21 at 10:20am, V3 (CNA) said she was taking R1 to an appointment at the hospital. V3 said she parked in the handicap parking in the front of the parking lot. V3 said she made it to the end of the sidewalk where there were red things for vision impaired. V3 said she hit the bumps with the wheelchair, and it made the wheelchair stop and R1 fell forward out of the chair. V3 said it happened so fast she could not catch (R1) from falling. V3 said that there was no way she could go around the red things due to the curbs. V3 was crying and said she does not know why she didn't put the footrests on the wheelchair. V3 said she knew to use them but just forgot. V3 said she came in just to take R1 to the appointment. V3 said the hospital staff got on her also for not using footrests on the wheelchair. V3 said the accident was like in slow motion and she couldn't stop it. On 4/18/23 at 3:45pm, this surveyor went to the hospital location where R1's fall incident occurred. The particular sidewalk where the fall occurred was observed to connect the parking lot area to the roadway area where patient/transport vehicles drop off near the hospital entrance. This area of the sidewalk was noted to have a decline of approximately 4 - 6 inches with truncated ADA tiles at the end of the sidewalk just before the roadway. Video surveillance footage provided by the hospital was reviewed. The surveillance footage dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 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 146175 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274 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 3/31/23 with a time stamp of 9:11 AM, shows V3 pushing R1 in a wheelchair on the sidewalk near the hospital entrance. As the wheelchair descended through the ADA truncated tiles onto the smooth roadway/ concrete surface, R1's left foot, followed by the right foot, are observed dropping and coming into contact with the concrete surface approximately 1 to 2 feet past the ADA truncated tile. R1 is then observed falling forward out of her wheelchair onto the concrete surface. There are no foot plates or foot rests observed on R1's wheelchair in the surveillance footage. On 4/18/23 at 10:40am, V5 (LPN/Licensed Practical Nurse) said she would expect staff to use a footrest when taking a resident out of the facility unless they are independent. On 4/18/21 at 10:50am, V4 (CNA/Certified Nurse Assistant) said if a resident does not really use their feet, she would use a footrest on the wheelchair when taking a resident out of the facility. On 4/18/23 at 10:45am, V6 (LPN/Licensed Practical Nurse) said she would expect that staff would use a footrest on the wheelchair when transporting a resident out of the facility. On 4/18/23 at 12:05pm, V8 (CNA/Certified Nurse Assistant) said that he would use footrests when he takes a resident out of the facility. On 4/18/23 at 2:15pm, V10 (family member of R1) said he volunteers and drives a golf cart around the parking lot of the local hospital. V10 said he was aware R1 had an appointment for a Doppler and went to where they parked. V10 said that the staff got R1 out of the back of the van and began pushing her on the sidewalk. V10 said he asked the staff if they needed any help, and they said no. V10 said he turned his head for a minute and when he looked back over, R1 had fallen forward out of the wheelchair and was bleeding. V10 said hospital staff came out and took her in for treatment. V10 said that from where they parked the car, it was maybe 50 feet to the entrance. V10 said there were bumps for the Disabilities Act and the wheels of the wheelchair like locked and she fell forward. V10 said that some days R1 is more with it and can tell you what she had for lunch, and then other times she cannot. V10 said that he and his brother had talked the evening after the accident about footrests on the wheelchair. V10 said he went to the facility the next day and talked with the Social Service person (V7) and told them he would like them to use footrests on her wheelchair. V10 said that R1 does not like them, and he told V7 that if they agitated R1, they could turn them to the side. V10 said he has been to the facility every day since the accident and the footrests have been on her wheelchair. On 4/19/23 at 10:06am, V13 (emergency room Director at local hospital) said that she and another nurse were on duty on 3/31/23 and went outside to where R1 was on the ground and assessed R1. V13 said they brought R1 on a gurney back into the ER (emergency room). V13 said that the staff with R1 was visibly upset and crying. V13 said that she noticed that staff did not have foot pedals on the wheelchair when pushing her. V13 said she talked to staff about using foot pedals when taking a resident out of the facility. V13 said that she told them how a resident's foot can drop and also cause an accident and to always use the footrest. Observations were made at various times during the day on 4/18/23, R1 was noted to have footrests on her wheelchair and did not appear to have anxiety about them being on her chair. Attempts to interview R1 were unsuccessful due to R1's impaired cognition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 3 of 3