Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
The Findings include:
R1's Face Sheet dated 10/23/2023 documents R1 being admitted to the facility on [DATE] with a diagnosis
of Major Depressive Disorder, recurrent, unspecified, Frontotemporal dementia, Barrett's esophagus with
dysplasia, unspecified, Type 2 diabetes mellitus without complications, Obstructive sleep apnea (adult)
(pediatric), Need for assistance with personal care, Unspecified osteoarthritis, unspecified site, Dementia in
other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, Dementia in
other diseases classified elsewhere, moderate, with psychotic disturbance. R1's Minimum Data Set (MDS)
dated [DATE], documents Section C, Brief Interview for Mental Status (BIMS) score is 2, severely, impaired,
cognition, Section GG, Independent with bed mobility, transfers, toileting, ambulating, eating, supervision
with touching assistance with dressing.
R1's Physician's Order dated for the month of October 2023 does not list any restraint ordered for R1.
On 10/24/2023, at 6:30 AM, V5, (Certified Nurse Aide /CNA) stated that she worked the night of
10/12/2023. V5 stated that when she came on her shift, she noticed R1 sitting up at the nurse's station. V5
stated that he was sitting there calmly, not trying to get up. V5 stated she went about her shift and noticed
R1 appeared to be looking tired. V5 stated that she asked him to come with her and she would help him get
ready for bed. V5 stated R1 usually walks independently but was not getting up from his wheelchair. V5
stated that she went over to R1 and took the blanket off him and noticed there was another blanket
underneath. V5 stated that she tried to take that blanket off R1, but noticed it was tied down to the
wheelchair. V5 stated that it took her about 2 minutes or so to get the bath blanket untied from the
wheelchair.V5 stated that V10 (CNA) came up to her and asked, Why are you putting R1 to bed?, I was
coming to do it. V5 stated that she asked V10, Who tied this blanket down on R1's wheelchair? V5 stated
that she told V10, We can't tie any resident down. V5 stated that V10 stated to her, I can't chase him around
all night, What are we supposed to do?. V5 stated that she went up to V8, (Licensed Practical Nurse /LPN)
and reported to her that she found R1 tied down with a bath blanket to his wheelchair. V5 stated that V8 just
looked at her and stated, Ok. V5 stated that after she put R1 to bed, he stayed in bed and slept all night. V5
stated that when V6 (LPN) came on
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
146175
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
10/24/2023
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 0604
her shift the next morning, she reported to her that she found R1 tied down with a bath blanket to his
wheelchair. V5 stated that V6 stated she would notify V1 (Administrator) and V2 (Director of Nursing/DON).
Level of Harm - Actual harm
Residents Affected - Few
On 10/23/2023, at 11:05 AM, V6 (LPN) stated that she worked 10/13/2023 on day shift. V6 stated that V5
(CNA) reported to her that when she was putting R1 to bed last night, she noticed that R1 was tied down
with bath blanket in his wheelchair. V6 stated that she reported this to V1 (Administrator) right away.
On 10/23/2023, at 12:00 PM, V1 (Administrator) stated that it was reported to her on 10/13/2023 that R1
was found to be tied down with a bath blanket in his wheelchair, the night before. V1 stated that an
investigation was initiated, all proper notifications were made (Power of Attorney, Police Department,
Primary Physician, & Ombudsman). V1 stated that R1's skin was assessed and there were no injuries
noted. V1 stated that it was founded that V10 (CNA) had tied R1 down with a bath blanket in his wheelchair.
V1 stated that V10 was immediately suspended and later terminated for not following policies and
procedures for LTC facilities. V1 stated that all staff were in-serviced on Use of Restraint/Reporting of
Reasonable Suspicion of a Crime.
On 10/23/2023, at 9:45 AM, attempted to contact V10 (CNA) by phone but was unable to get in contact with
him.
The facility's final investigation report dated 10/17/2023 documents in parts . It was reported on 10/13/2023
that V10 (CNA) had tied R1 in a wheelchair using a bath blanket around 6:30 PM the night before. Nurse
assessment completed on R1, and no injuries were noted. V10 was suspended until further investigation.
V12 (Family), Local Police Department, V13 (Primary Physician) and Ombudsman were notified. On
10/13/2023, V1 (Administrator) interviewed V5 (CNA), and she stated when she came on shift at 10:00 PM,
10/12/2023, she walked down the hall to the nurse's station, as she approached the nurse's station, she
saw R1 and another resident sitting along the wall. V5 stated that R1 was not trying to get up, he was just
minding his own business with a blanket draped across him. V5 started to get him out of the wheelchair and
noticed he was not moving. V5 asked R1 what was wrong, and he just looked at her, that is when V5
noticed another blanket was still across his waist. V5 tried to pull it off and realized someone tied R1 to the
wheelchair with a bath blanket prior to her coming on shift. V10 (CNA) walked by and stood in the doorway
to R1's room and asked, What are you doing? V10 stated multiple times he was going to lay R1 down. V5
walked back down the hallway and told V10 that she doesn't know who did that to R1, but it was not ok. V5
went to the nurse's station and told the charge nurse, V8 (LPN). V5 stated that V8 just looked at her and
said, Ok. V5 waited until day shift nurses got to the facility and told V6 (LPN) what had happened and V6
stated she would let the Director of Nursing know. V1 was notified of this incident on 10/13/2023, at 8:45
AM. V1 notified V12 (Family), V13 (Primary Physician), Local Police, and Ombudsman. A facility wide
In-Service was conducted on Use of Restraints and Reporting of Reasonable Suspicion of a Crime in a
Long-Term care facility .After further investigation, we find that V10 (CNA) needs to be terminated for not
following policies and procedures for Long-Term care facilities.
There was no restraint assessment included in R1's Clinical Records to indicate the use of bath blankets as
a restraint.
The facility's policy, Use of Restraints, dated April 2017, documents under Policy Statement: Restraints
should only be used to treat the resident's medical symptoms and never for discipline or for staff
convenience, or for the prevention of falls. 4. Practices that inappropriately utilize
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146175
If continuation sheet
Page 2 of 5
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
10/24/2023
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 0604
Level of Harm - Actual harm
Residents Affected - Few
equipment to prevent resident mobility are considered restraints and are not permitted, including: b. Tucking
sheets so tightly that a bed-bound resident cannot move; c. Placing a resident in a chair that prevents the
resident from rising; 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment
and review to determine the need for restraints. The assessment shall be used to determine possible
underlying causes of the problematic medical symptoms and to determine if there are less restrictive
interventions (programs, devices, referrals, etc.) that might improve the symptoms; 9. Restraints shall only
be used upon a written order from the physician and after obtaining a consent from the resident and
or/representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as
it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's
medical symptom; and c. The type of restraint and the period of time for the use of the restraint.
Prior to the survey date, the facility took the following actions to correct the deficient practice:
1. A Quality Assurance and Performance Improvement meeting was held on 10/13/23. In attendance - V1,
V2.
2. Measures that were put into place/systematic changes to ensure the deficient practice does not recur: V1
and V2 (DON) provided in-service to all facility staff regarding Restraint Usage/Reporting of Reasonable
Suspicion of a Crime on 10/13/23.
3. Plan to monitor performance to ensure solutions are sustained: Restraint audits to be conducted daily by
V1 & V2. The first complete facility audit was completed on 10/13/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146175
If continuation sheet
Page 3 of 5
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
10/24/2023
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The Findings include:
R1's Face Sheet dated 10/23/2023 documents being admitted to the facility on [DATE] with a diagnosis of
Major Depressive Disorder, recurrent, unspecified, Frontotemporal dementia, Barrett's esophagus with
dysplasia, unspecified, Type 2 diabetes mellitus without complications, Obstructive sleep apnea (adult)
(pediatric), Need for assistance with personal care, Unspecified osteoarthritis, unspecified site, Dementia in
other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, Dementia in
other diseases classified elsewhere, moderate, with psychotic disturbance. R1's Minimum Data Set (MDS)
dated [DATE], documents Section C, Brief Interview for Mental Status (BIMS) score is 2, severely, impaired,
cognition, Section GG, Independent with bed mobility, transfers, toileting, ambulating, eating, supervision
with touching assistance with dressing.
On 10/24/2023, at 6:30 AM, V5, Certified Nurse Aide (CNA) stated that she worked the night of 10/12/2023.
V5 stated that when she came on her shift, she noticed R1 sitting up at the nurse's station. V5 stated that
he was sitting there calmly, not trying to get up. V5 stated she went about her shift and noticed R1
appeared to be looking tired. V5 stated that she asked him to come with her and she would help him get
ready for bed. V5 stated R1 usually walks independently but was not getting up from his wheelchair. V5
stated that she went over to R1 and took the blanket off him and noticed there was another blanket
underneath. V5 stated that she tried to take that blanket off R1, but noticed it was tied down to the
wheelchair. V5 stated that it took her about 2 minutes or so to get the bath blanket untied from the
wheelchair V5 stated that V10 (CNA) came up to her and asked, Why are you putting R1 to bed?, I was
coming to do it. V5 stated that she asked V10, Who tied this blanket down on R1's wheelchair? V5 stated
that she told V10, We can't tie any resident down. V5 stated that V10 stated to her, I can't chase him around
all night, What are we supposed to do? V5 stated that she went up to V8 (Licensed Practical Nurse /LPN)
and reported to her that she found R1 tied down with a bath blanket to his wheelchair. V5 stated that V8 just
looked at her and stated, Ok. V5 stated that when V6 (LPN) came on her shift the next morning, she
reported to her that she found R1 tied down with a bath blanket to his wheelchair. V5 stated that V6 stated
she would notify V1 (Administrator) and V2 (Director of Nursing/DON).
On 10/23/2023, at 11:05 AM, V6 (LPN) stated that she worked 10/13/2023 on day shift. V6 stated that V5
(CNA) reported to her that when she was putting R1 to bed last night, she noticed that R1 was tied down
with bath blanket in his wheelchair. V6 stated that she reported this to V1 (Administrator) right away.
On 10/23/2023, at 12:00 PM, V1 (Administrator) stated that it was reported to her on 10/13/2023 that R1
was found to be tied down with a bath blanket in his wheelchair, the night before. V1 stated that at that time
an investigation was initiated, all proper notifications were made (Power of Attorney, Police Department,
Primary Physician, & Ombudsman).
The facility's final investigation report dated 10/17/2023 documents in part . It was reported on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146175
If continuation sheet
Page 4 of 5
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
10/24/2023
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 0609
Level of Harm - Minimal harm
or potential for actual harm
10/13/2023 that V10 (CNA) had tied R1 in a wheelchair using a bath blanket around 6:30 PM the night
before . V5 went to the nurse's station and told the charge nurse, V8 (LPN). V5 stated that V8 just looked at
her and said, Ok. V5 waited until day shift nurses got to the facility and told V6 (LPN) what had happened
and V6 stated she would let the Director of Nursing know. V1 was notified of this incident on 10/13/2023, at
8:45 AM.
Residents Affected - Few
The facility's undated policy Reporting of Reasonable Suspicion of a Crime in a Long-Term Care Facility
documents in part under: What should be reported and to whom: All alleged violations involving
mistreatment, neglect, sexual, or abuse, including injuries of unknown source and misappropriation of
resident property are to be reported immediately to the administrator.
Prior to the survey date, the facility took the following actions to correct the deficient practice:
1. A Quality Assurance and Performance Improvement meeting was held on 10/13/23. In attendance - V1,
V2.
2. Measure put into place/systematic changes to ensure the deficient practice does not recur: V1 and V2
(DON) provided in-service to all facility staff regarding Restraint Usage/Reporting of Reasonable Suspicion
of a Crime dated 10/13/2023.
3. Plan to monitor performance to ensure solutions are sustained: Reporting/Notification audits to be
conducted daily by V1 & V2. The first complete reporting/notification audit was completed on 10/13/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146175
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ · About this visit
Common questions about this visit
What happened during the October 24, 2023 survey of PINCKNEYVILLE NURSING & REHAB?
This was a inspection survey of PINCKNEYVILLE NURSING & REHAB on October 24, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PINCKNEYVILLE NURSING & REHAB on October 24, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.