Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
Findings include:
1. R11's Face Sheet, dated 03/21/24 documents R11 was admitted to the facility on [DATE] with a
diagnosis of diagnosis documents Spondylolysis, lumbar region, Depression, unspecified, Hyperlipidemia,
unspecified, Benign prostatic hyperplasia without lower urinary tract symptoms, Chronic obstructive
pulmonary disease, Anxiety disorder, Hereditary and idiopathic neuropathy, Essential (primary)
hypertension, Weakness, Repeated falls, and Obstructive and reflux uropathy.
R11's Current Care Plan, documents R11 requires assistance for all ADL'S (Activities of Daily Living) with a
start date of 03/09/23, interventions include Refer to Occupational Therapy to work on ADL (Activities of
Daily Living) re-training, give verbal cues to help prompt, break tasks up into smaller steps, and allow rest
breaks between tasks.
R11's Minimum Data Set (MDS), dated [DATE], documents R11 has a Brief interview for Mental Status
(BIMS) of 15 which indicates R11 is cognitively intact and is dependent on staff for transfers, toileting,
dressing, and personal hygiene. R11 has an indwelling catheter and is always incontinent of bowel.
On 03/19/24 at 9:49AM, R11 stated he doesn't like that he doesn't have a privacy curtain in between him
and his roommate. R11 said he does have a curtain to block the outside people from looking in but doesn't
have anything to separate him and his roommate. R11 said when he gets his bed baths that his roommate
can see everything. R11 said that V11 (Housekeeper) told him that the track is broken to the curtain, so she
removed the curtain, so the track does not fall down. R11 stated that it doesn't embarrass him when he
takes a bed bath in the room and his roommate is in there but that it is more annoying that he must take a
bed bath with him in there.
On 03/19/24 at 9:52AM while in R11's room it was noted that the track in the middle of the room was
hanging down with no curtain on it.
On 03/20/24 at 1:15PM, V11 stated that she took down the privacy curtain in R11's room around February,
because the track was falling, and the curtain was dragging on the ground. V11 said that she did notify V10
(Maintenance) about taking the track coming off the ceiling and that she removed the curtain. V11 said that
V10 told her that he would work on it when he can. V11 said that is the only curtain that she has removed.
V11 said there are several other tracks that are coming loose, and she
(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
03/21/2024
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 0583
has notified V10 about them. V11 stated she was unaware if V10 has taken care of those tracks or not yet.
Level of Harm - Minimal harm
or potential for actual harm
2. R40's Face sheet, dated 03/21/24, documents R40 was admitted to the facility on [DATE] with a
diagnosis of Cellulitis, unspecified, Personal history of other venous thrombosis and embolism, Opioid
abuse, uncomplicated, Generalized anxiety disorder, Other idiopathic peripheral autonomic neuropathy, and
Depression.
Residents Affected - Few
R40's Current Care Plan, documents Self Care deficit with a start date of 10/27/22 with interventions of:
assist with ambulation, transfers, and locomotion as needed, assist with dressing/undressing, assist with
meals prn (as needed), assist with oral/dental hygiene, and encourage resident to perform self-care if able.
R40's Minimum Data Set, dated [DATE], documents that R40 has cognitive impairment and is dependent
on staff for toileting, transfers, dressing, and bathing. R40 is always incontinent of bowel and bladder.
On 03/19/24 at 12:50 PM, R40 who was alert and oriented to person place and time during interview stated
that he hasn't had a curtain that divides him from his roommate the entire time he has been in that room.
R40 was unsure how long he has been in his current room. R40 said he doesn't have any privacy. R40 said
that they perform care on him when his roommate is in the room. R40 said it annoys him that he can't have
any privacy. R40 said they don't do anything that allows him privacy when they perform care on him. R40
said that his roommate just sits over there on his bed while he receives care.
On 03/19/24 at 12:52PM, while in R40's room there was no curtain track in the room between R40's bed
and his roommate bed. There was a curtain that wraps around the door and the window, but nothing in
between the two residents in the room to allow privacy for them.
On 03/20/24 at 1:30PM, V10 who stated that he was aware that he had a track down in R40's room. V10
said that he ordered a new track and curtain for R40's room and he was supposed to be putting that track
and curtain up today. V10 said he wasn't sure how long the track and curtain had been missing from the
ceiling in R40's room he thought maybe a couple of days or so. V10 said that he didn't know that R11's
curtain was removed, until he observed the curtain being down. V10 said he had forgot V11 did notify him
that the track was coming down in R11's and V11 removed the curtain. V10 said that he will work on putting
a screw in the track in R11's room and getting it fixed so they can put a curtain back up.
On 03/21/24 at 10:30AM, V3 (Director of Operations) provided the maintenance logbook with no evidence
of work order for curtain and track repair to R11 and R40's rooms. No evidence noted in maintenance
logbook for repair request.
Facility Policy Confidentiality of Information and Personal Privacy with a revision date of October 2017
documents under Policy statement Our facility will protect and safeguard resident confidentiality and
personal privacy. Policy Interpretation and Implementation states in part: The facility will strive to protect the
resident's privacy regarding his and her: medical treatment and personal care.
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
03/21/2024
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 0638
Assure that each resident’s assessment is updated at least once every 3 months.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.
Residents Affected - Few
Findings include:
R149 Face Sheet documents an admission date 05/01/23 with diagnosis including: Depression, Atrial
fibrillation, Anxiety, Disorder, Type 2 Diabetes Mellitus, Dementia, and Bipolar Disorder.
R149's Electronic Health Records documents there was a quarterly Minimum Data Sheet (MDS) done on
10/20/23. R149's EHR also documents that R149 had a readmission MDS for the date of 12/19/23 that was
not signed and dated until 3/18/24 and then a new quarterly MDS that was signed and dated 3/19/24.
On 03/20/24 at 1:10 PM when asked about why R149 had not had an updated readmission and quarterly
MDS conducted V3 (Regional Administrator) stated they missed an MDS assessment and is put in the
system now, but it will be late.
On 03/21/24 at 9:50 AM, V14 (MDS/Care Plan Coordinator) stated, they had missed the quarterly MDS
assessment for R149, R149 should have had another quarterly done around 01/20/24 she believes. V14
stated they missed an assessment for R149.
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
03/21/2024
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 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based 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.
Residents Affected - Many
Findings included:
On 3/18/2024 at 11:00am and 1:00pm, the facility was observed to not have a Daily Nurse Staffing data
sheet posted in a prominent place readily accessible to residents and visitors.
On 3/19/2024 at 1:25pm, V1 (Administrator) said Daily Nurse Staffing Data is posted at the nurse's station.
On 3/19/2024 at 1:30pm, Daily Nurse Staffing Data sheet was not posted at the facility's nurse station.
On 3/19/2024 at 1:30pm, V4 (Licensed Practical Nurse/LPN) was sitting at the nurse's station and asked to
point out where the Daily Nurse Staffing Data sheet was posted. V4 pointed to a sheet of paper on a clip
board behind the nurse's station. The undated paper was titled Nurse Daily Assignment Sheet. V4 (LPN)
said the paper she pointed to did not include a current date, current resident census, the facility's name, the
total number of licensed and unlicensed staff or the actual hours worked per shift of the licensed and
unlicensed staff. V4 said the administration used to post the daily nurse staffing data sheet up in the dining
room, but she has not seen this for several months.
On 3/19/2024 at 2:15pm, V1 said the form titled Nurse Daily Assignment Sheet is what she is calling the
Daily Nurse Staffing Data sheet. V1 said she had never posted a Daily Nurse Staffing sheet since she
became administrator at this facility, and she has been the Administrator of this facility since 10/9/2023.
On 3/20/2024 at 8:45am and 1:00pm, the facility was observed to not have a Daily Nurse Staffing data
sheet posted in a prominent place readily accessible to residents and visitors.
A facility document titled Census List and dated 3/20/2024 documents 47 residents reside at this facility.
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
03/21/2024
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 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based 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.
Findings include:
Observation on 3/20/2024 at 2:30pm revealed R12 and R5 shared a bedroom. It was a smaller sized
bedroom with two beds, two bedside tables, an arm chair, an over the bed table, a geriatric wheelchair and
had limited area to move around inside the room. A built in dresser was observed in the room as well, but
did not affect the living area.
Observations on 3/20/2024 at 2:35pm revealed R29 and R45 shared a bedroom. It was a smaller sized
bedroom with two beds, two bedside tables, an arm chair, an over the bed table, two wheelchairs and had
limited area to move around inside the room. A built in dresser was observed in the room as well, but did
not affect the living area.
During a tour with V3 (Director of Operations) on 3/21/2024 at 10:15am, V3 was asked to measure R12,
R5, R29 and R45's bedroom sizes. V3 used a measuring tape to measure the length and width of R12 and
R5's bedroom and stated, 12.6 by 12 [feet] [which was equivalent to 151.2 square feet/75.6 feet per
resident bed]. The measurement did not include the closet, toilet room and built in dresser area. At
approximately 10:17am, V3 measured R29 and R45's bedroom and stated, 12.6 by 12 [feet] [which was
equivalent to 151.2 square feet/75 feet per resident bed]. The measurement did not include the closet, toilet
room and built in dresser area.
During an interview on 3/21/2024 at 10:20am with V3, when asked about the size required for two-resident
bedroom, V3 stated, The room has to be over 80 [square feet each] for two residents.
On 3/21/24 at 11:00 AM when V3 was asked if residents were notified during admission that many of the
rooms in the facility did not meet the requirement of having 80 square feet per resident V3 stated he was
unsure if it was in the contract but stated that residents were told verbally that rooms on the A Hall and B
Hall were a little smaller. V3 stated that when a Medicare resident was admitted normally there were
admitted to one of the rooms that met the size requirement and moved later on to a Medicaid only or
private pay room which were smaller rooms. V3 stated there are only 2 single person rooms in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146175
If continuation sheet
Page 5 of 5
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 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.
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
FAQ · About this visit
Common questions about this visit
What happened during the March 21, 2024 survey of PINCKNEYVILLE NURSING & REHAB?
This was a inspection survey of PINCKNEYVILLE NURSING & REHAB on March 21, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PINCKNEYVILLE NURSING & REHAB on March 21, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assure that each resident’s assessment is updated at least once every 3 months."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.