Health inspection·October 7, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some Findings include: 1. R4's admission record documents an admission date of 1/6/24, with diagnoses in part; Alzheimer's disease, late onset, Unspecified dementia, depression, dizziness, delusional disorders and vertigo. R4's Minimum Data Set (MDS) dated [DATE], records a Brief Interview for Mental Status (BIMS) of 9, indicating that R4 is mildly cognitively impaired. R4's current care plan documents that she is at risk for falls, has behaviors and is totally dependent on staff for Completing ADL's. On 10/02/2024 at 9:16am, an attempt to interview R4 was made and R4 was not interviewable. R4's shower days documented in is Summary Order Report are Wednesdays and Saturdays. R4 has a document titled Skin Observation: Comprehensive shower review for Saturday 9/14/24 (bed bath) and Saturday 9/28/24. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat, 9/7, Wed 9/11, Wed 9/18, Sat 9/21, Wed 9/25. 2. R5's admission record documents an admission date of 01/15/2016 with diagnoses in part; abnormalities of gait and mobility, dermatitis, insomnia, chronic pain syndrome, vitamin D deficiency, muscle weakness and constipation. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating that R5 is cognitively intact. Section GG documents he is independent with toileting hygiene and bathing but requires assistance with transferring. R5's current care plan documents that R5 is at risk for falls and is to ask for staff assistance with toileting. R5's Order Summary Report documents R5's shower days are Tuesdays and Fridays. Page 1 of 8 146175 146175 10/07/2024 Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R5 has a document titled Skin Observation: Comprehensive shower review for Tuesday 9/3/24 and Thursday 9/12/24 (refusal). No documentation of showers or refusals were found for the following shower days; Fri 9/5, Tues 9/10, Tues 9/17, Fri 9/19, Tues 9/24, Fri 9/28. On 10/3/24 at 2:39pm, R5 stated his care is pretty good here. R5 stated he wasn't sure if he got showers like he was supposed to, but they keep him clean. R5 stated they need some more staff badly. R5 stated they are a little slow on the lights, but it is more of an issue at night. R5 stated if you are in the bathroom, the staff are quick to respond, but the regular room lights not so much. R5 stated he is supposed to call for help to transfer, especially to the bathroom, but sometimes he just can't wait on them any longer. R5 stated he even has a sign in his bathroom that says he should call for help. R5 stated he did have a recent fall, he was trying to transfer out of his bed to go to the bathroom and slid in between the bed and chair. R5 stated he was not injured, and it has happened multiple times before. An incident report in R5's medical record for an unwitnessed fall on 09/26/24, documents that R5 slipped trying to get out of bed. 3. R6's admission record documents an admission date of 5/13/2018 with diagnoses in part cognitive communication deficit, abnormalities of gait and mobility, need for assistance with personal care, unsteadiness on feet, vascular dementia, osteoarthritis and muscle weakness. R6's Minimum Data Set (MDS) dated [DATE], documents a Brief interview for mental status (BIMS) of 2, indicating that R6 is severely cognitively impaired. Section GG documents R6 requires assistance for transfers and is dependent on staff for Toileting hygiene and bathing. R6's Order Summary Report documents R6's shower days are Wednesday and Saturday. R6 has a document titled Skin Observation: Comprehensive shower review for Wed 9/4, Wed 9/11, Sat 9/14, Wed 9/18 and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Sat 9/7, Sat 9/21, Weds 9/25. 4. R7's admission record documents an admission date of 06/03/2024 with diagnoses in part; urinary tract infection, acute kidney failure, osteoarthritis, urinary incontinence and pain in unspecified joint. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief interview for mental status (BIMS) of 00, indicating that R7 is severely cognitively impaired. Section GG documents that R7 requires assistance with toileting hygiene and showering/bathing, dressing and personal hygiene. R7's Order Summary Report documents R7's shower days are Wednesday and Saturday. R7 has a document titled Skin Observation: Comprehensive shower review for Fri 9/13, Sat 9/14, and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat 9/7, Wed 9/18, Sat 9/21 and Wed 9/25. R7's progress notes document the following, 10/2/2024 2:47pm, SHOWER EVERY WEDNESDAY, SATURDAY. one time a day every Wed, Sat for STANDING ORDER. Bed bath short staffed. On 10/92/2024 at 9;03am, R7 was observed sitting in her chair, in clean dry clothing, her hair 146175 Page 2 of 8 146175 10/07/2024 Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274

F 0677 appeared dirty and unkept and she was only wearing one sock. Level of Harm - Minimal harm or potential for actual harm 5. On 10/3/24 at 11:00am, V9 (Family Member) stated they do not have enough CNA's to go around here. V9 stated on two occasions, R9 sat for over 4 hours in wet pants. V9 stated both times she left and alerted staff to it and when she came back, he was still in the same wet pants. V9 stated that the CNA's do all that they can, she stated they will literally bend over backwards for us but there just is not enough to go around. V9 stated that if it wasn't for her children, she would have already moved R9. V9 stated in the beginning of his stay in August, she did not feel like he was very clean. But now she has no complaints about that, his face and hair look clean everyday she comes in, she stated she wishes incontinence care was a little better. Residents Affected - Some On 10/2/24 at 9:10am, V3 (Licensed Practical Nurse/LPN) stated lately on a normal day they only have three CNA's (Certified Nursing Assistant) but sometimes they only have two. V3 stated it has been a problem for a while, but it's definitely gotten worse since COVID has hit the building. V3 stated that there are 12 or 13 residents who require total assistance with meals and a lot of residents with behaviors who require one on one supervision. V3 stated it's just hard for the CNA's to get everything done with all that on top of it. V3 stated she can usually assist the CNA's with some of their duties and still complete her own, but everyone is stretched thin right now and any little bump in the road can change that. V3 stated that V1 (Administrator) and V5 (Social Services Director) are always out on the floor helping them as much as they can. On 10/2/24 at 9:21am, V6 (CNA) stated lately she has been the only CNA to show up the past three mornings. V6 stated midnights does stay and help though, so does V1 and V5. V6 stated at this moment there are only 2 CNA's that are assigned to the floor in the building. V6 stated they barely have time to give showers, that they have been having to wash people up in bed. V6 stated that they make sure that everyone is clean though. V6 stated they are supposed to complete shower sheets for showers and refusals. V6 stated that V1 and V5 were always on the floor trying to help them. On 10/2/24 at 10:18am, V1 (Administrator) stated that last week was a rough week for CNA's for sure. V1 stated that staff are expected to finish charting, even if they have to stay over, but that patient care comes first. V1 stated at the end of the day, the floor staff has been at it all day for several days and just want to go home. V1 stated showers are to be done twice a week and the scheduled days are in their orders, shower sheets are to be completed. On 10/2/24 at 12:56pm, V3 (LPN) and V4 (LPN) were observed trying to make calls to get staff to cover the next shift. V3 and V4 stated that residents have scheduled shower days and staff are expected to fill out shower sheets when they give residents a shower and for a refusal. On 10/3/24 at 10:49am, V7 (CNA) stated most days it is hard to get everything done. V7 stated there are several days she has worked the A hall by herself, she stated that hallway is the heaviest hallway and many of the residents often require the assistance of two people. V7 stated there are a lot of people in the building that require lots of assistance and plenty of people with behaviors. V7 stated she was not here for the past two weeks, but it just keeps getting worse and worse. V7 stated V1 (Administrator) and V5 (Social Services Director) are always trying to help how they can. V7 stated V2 (Director of Nursing/DON) will not leave the office unless he has a question for someone. V7 stated if you ask V2 for help, he will tell you to go find a CNA. V7 stated V2 will not even help the nurses. On 10/3/24 at 10:51am, V8 (CNA) stated they are always short staffed, it just keeps getting worse. 146175 Page 3 of 8 146175 10/07/2024 Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some V8 stated she is a PRN (as needed) employee, and they are constantly calling her to cover shifts. V8 stated that it is hard to complete job duties but that they try to make sure everyone is clean and taken care of the best we can. Facility policy titled Bath, Shower/Tub with a revision date of February 2018 documents the following under documentation, If a resident refused the shower/tub bath, the reason(s) why and the intervention taken. It is to be reported to the supervisor if the resident refuses. 146175 Page 4 of 8 146175 10/07/2024 Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Resident Matrix dated 10/2/2004 documents there are 45 residents living in the facility. 1. On 10/3/24 at 2:39pm, R5 stated his care is pretty good here. R5 stated he wasn't sure if he got showers like he was supposed to, but they keep him clean. R5 stated they need some more staff badly. R5 stated they are a little slow on the lights, but it is more of an issue at night. R5 stated if you are in the bathroom, the staff are quick to respond, but the regular room lights not so much. R5 stated he is supposed to call for help to transfer, especially to the bathroom, but sometimes he just can't wait on them any longer. R5 stated he even has a sign in his bathroom that says he should call for help. R5 stated he did have a recent fall, he was trying to transfer out of his bed to go to the bathroom and slid in between the bed and chair. R5 stated he was not injured, and it has happened multiple times before. R5's admission record documents an admission date of 01/15/2016 with diagnoses in part; abnormalities of gait and mobility, dermatitis, insomnia, chronic pain syndrome, vitamin D deficiency, muscle weakness and constipation. R5's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating that R5 is cognitively intact. R5's MDS documents in section GGR5's current care plan documents that R5 is at risk for falls and is to ask for staff assistance with toileting. An incident report in R5's medical record for an unwitnessed fall on 09/26/24, documents that R5 slipped trying to get out of bed. R5's Order Summary Report documents R5's shower days are Tuesdays and Fridays. R5 has a document titled Skin Observation: Comprehensive shower review for Tuesday 9/3/24 and Thursday 9/12/24 (refusal). No documentation of showers or refusals were found for the following shower days; Fri 9/5, Tues 9/10, Tues 9/17, Fri 9/19, Tues 9/24, Fri 9/28. 2. R4's admission record documents an admission date of 1/6/24, with diagnoses in part; Alzheimer's disease, late onset, Unspecified dementia, depression, dizziness, delusional disorders and vertigo. R4's current care plan documents that she is at risk for falls, has behaviors and is totally dependent on staff for Completing ADL's. R4's shower days documented in is Summary Order Report are Wednesdays and Saturdays. R4 has a document titled Skin Observation: Comprehensive shower review for Saturday 9/14/24 (bed 146175 Page 5 of 8 146175 10/07/2024 Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many bath) and Saturday 9/28/24. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat, 9/7, Wed 9/11, Wed 9/18, Sat 9/21, Wed 9/25. 3. R6's admission record documents an admission date of 5/13/2018 with diagnoses in part cognitive communication deficit, abnormalities of gait and mobility, need for assistance with personal care, unsteadiness on feet, vascular dementia, osteoarthritis and muscle weakness. R6's Minimum Data Set (MDS) dated [DATE], documents a Brief interview for mental status (BIMS) of 2, indicating that R6 is severely cognitively impaired. Section GG documents R6 requires assistance for transfers and is dependent on staff for Toileting hygiene and bathing. R6's Order Summary Report documents R6's shower days are Wednesday and Saturday. R6 has a document titled Skin Observation: Comprehensive shower review for Wed 9/4, Wed 9/11, Sat 9/14, Wed 9/18 and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Sat 9/7, Sat 9/21, Weds 9/25. 4. R7's admission record documents an admission date of 06/03/2024 with diagnoses in part; urinary tract infection, acute kidney failure, osteoarthritis, urinary incontinence and pain in unspecified joint. R7's Minimum Data Set (MDS) dated [DATE] documents a Brief interview for mental status (BIMS) of 00, indicating that R7 is severely cognitively impaired. Section GG documents that R7 requires assistance with toileting hygiene and showering/bathing, dressing and personal hygiene. R7's Order Summary Report documents R7's shower days are Wednesday and Saturday. R7 has a document titled Skin Observation: Comprehensive shower review for Fri 9/13, Sat 9/14, and Sat 9/28. No documentation of showers or refusals were found for the following shower days; Wed 9/4, Sat 9/7, Wed 9/18, Sat 9/21 and Wed 9/25. R7's progress notes document the following, 10/2/2024 2:47pm, SHOWER EVERY WEDNESDAY, SATURDAY. one time a day every Wed, Sat for STANDING ORDER. Bed bath short staffed. On 10/2/2024 at 9;03am, R7 was observed sitting in her chair, in clean dry clothing, her hair appeared dirty and unkept and she was only wearing one sock. On 10/2/24 at 9:08am, R1 who was alert to person place and time stated her care is fine. She stated she feels like it takes a little longer to get help, but they take great care of her here. On 10/02/24 at 1:05pm, R3 stated she was looking for someone to help her. R3 stated she's always trying to find someone to help her. R3 appeared to be alert to person only. On 10/2/24 at 1:06pm, R2 who was alert to person, place and time stated the staff here tries to help him as much as they can. R2 stated sometimes it takes them a little while to get to him, but they do a good job helping him. R2 stated there's not a lot of them to go around. On 10/2/24 at 1:13pm, R8 who was alert to person, place and time stated, you don't want to ask me about the staff. R8 stated they are always busy. 146175 Page 6 of 8 146175 10/07/2024 Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 10/2/24 at 9:11am, V3 (Licensed Practical Nurse/LPN) stated lately on a normal day they only have three CNA's (Certified Nursing Assistant) but sometimes they only have two. V3 stated it has been a problem for a while, but it's definitely gotten worse since COVID has hit the building. V3 stated that there are 12 or 13 residents who require total assistance with meals and a lot of residents with behaviors who require one on one supervision. V3 stated it's just hard for the CNA's to get everything done let alone with all that on top of it. V3 stated she can usually assist the CNA's with some of their duties and still complete her own. But everyone is stretched thin right now and any little bump in the road can change that. V3 stated that V1 (Administrator) and V5 (Social Services Director) are always out on the floor helping them as much as they can, V2 (DON) not so much. V3 stated she had mentioned to V1 about how another facility offers incentive bonuses or sign on bonuses and she had spoken with several people in corporate and it never went anywhere. On 10/2/24 at 9:21am, V6 (CNA) stated lately she has been the only CNA to show up the past three mornings, midnights does stay and help though, So does V1 and V5. V6 stated they barely get breaks and if they get a lunch, it usually isn't until 2 or 3pm, her shifts are 6a-6p. V6 stated at this moment there are only 2 CNA's that are assigned to the floor in the building. V6 stated they barely have time to give showers, that they have been having to wash people up in bed. V6 stated that they make sure that everyone is clean though. V6 stated they are supposed to complete shower sheets for showers and refusals. V6 stated that V1 and V5 were always on the floor trying to help them. On 10/2/24 at 12:56pm, V3 and V4 were observed trying to make calls to get staff to cover the next shift. V3 and V4 stated that residents have scheduled shower days and staff are expected to fill out shower sheets when they give residents a shower and for a refusal. On 10/2/24 at 1:29pm, V1 (Administrator) stated she tries to do what she can to get more staff in here. V1 stated from what she has heard from staff about other facilities, their wages are not competitive to bring in new staff or retain current staff. On 10/3/24 at 10:49am, V7 (CNA) stated most days it is hard to get everything done. V7 stated there are several days she has worked the A hall by herself, she stated that hallway is the heaviest hallway and many of the residents often require the assistance of two people. V7 stated there are a lot of people in the building that require lots of assistance and plenty of people with behaviors. V7 stated she was not here for the past two weeks, but it just keeps getting worse and worse. V7 stated V1 (Administrator) and V5 (Social Services Director) are always trying to help how they can. V7 stated V2 (Director of Nursing/DON) will not leave the office unless he has a question for someone. V7 stated if you ask V2 for help, he will tell you to go find a CNA. V7 stated V2 will not even help the nurses. On 10/3/24 at 10:51am, V8 (CNA) stated they are always short staffed, it just keeps getting worse. V8 stated she is a PRN (as needed) employee, and they are constantly calling her to cover shifts. V8 stated that it is hard to complete job duties but that they try to make sure everyone is clean and taken care of the best we can. On 10/3/24 at 11:00am, V9 (Family Member) stated they do not have enough CNA's to go around here. V9 stated on two occasions, R9 sat for over 4 hours in wet pants. V9 stated both times she left and alerted staff to it and when she came back he was still in the same wet pants. V9 stated that the CNA's do all that they can, she stated they will literally bend over backwards for us but there just is not enough to go around. V9 stated that if it wasn't for her children, she would have already moved R9. V9 stated in the beginning of his stay in August, she did not feel like he was very clean. But 146175 Page 7 of 8 146175 10/07/2024 Pinckneyville Nursing & Rehab 708 Virginia Court Pinckneyville, IL 62274

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many now she has no complaints about it, his face and hair look clean everyday she comes in, she stated she wishes incontinence care was a little better. On 10/3/24 at 2:00pm, it was observed that there were only 2 CNA's in the building and on the floor. On 10/2/24 at 2:10pm, V1 stated that there is no policy specific to call ins. V1 stated it is a known practice that it is all hands on deck, management, and everyone, we do our best to try to call people in, but everyone has something going on or they are tired. A review of Nursing and CNA schedules from 09/11-10/08 revealed instances where there were only 2 CNA's on the floor for two or more hours on the following days; 9/20, 10/01, 10/3. There was only one CNA on the floor on 9/30 from 6:00am to 2:00pm. 146175 Page 8 of 8