Inspection·November 12, 2024

F 0684 Nursing/DON) and V2 stated I will look but I didn't know about that. Level of Harm - Minimal harm or potential for actual harm On 11/11/2024 at 2:48PM, V2 stated there is no record of R1 going to the dermatologist. V2 said that R1 did not go to the dermatologist as the nurses thought V3 was going to make the arrangements for the appointment. V2 stated it is a miscommunication with the orders. V2 was asked about the biopsy that was noted to be done if the rash was not cured as documented in R1's Progress Note dated 10/3/24. V2 stated he didn't know anything about that. V2 stated well that did not happen either again a miscommunication. V2 said he doesn't think V3 has an office to do this procedure and doesn't know the specifics on what office the note is referring to. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 2 of 11 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 11/12/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few Findings include: 1.R1's admission Record documents an admission date of 2/24/2023 including diagnoses of Anxiety, Anorexia, Hyperlipidemia, Alzheimer's Disease, and Dementia. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 1 indicating R1 has severe cognitive impairment. R1's Care Plan documents a risk for alteration in skin integrity dated 2/24/2024 with interventions including: Medication for complaint of itching to be given as ordered by MD (physician) dated 9/18/24, referred to (name of local dermatology office) dated 10/11/24, and MD update about current skin status new orders received see Physician's Order Sheets (POS) for orders dated 10/16/2024. On 11/1/2024 at 9:38AM, V5 (Licensed Practical Nurse/LPN) stated we have a few people with rashes. V5 stated R1 has had a rash for a long time, and we just can't figure out what it is. V5 stated R1 has been on Prednisone at least 3 times and many different creams and nothing seems to help. V5 stated we even changed her laundry soap and her body wash, and nothing has really helped. V5 stated she scratches all the time. It is sad and I wish we knew what it was. V5 stated it is a peculiar rash and I don't think it is scabies, but I am not sure. On 11/1/2024 at 10:30AM V2 (Director of Nursing) stated they have not done a 100% skin audit on all the residents in the facility yet. V2 stated none of the residents have been seen by a Dermatologist yet. V2 stated he wasn't sure what R1's rash was from, but she has been treated with Prednisone several times and different creams with not really any relief. V2 stated that V4 (Medical Director) came in and ordered Permethrin (Scabicide/Pediculicide cream) and that helped the most. V2 stated he was the facilities Infection Preventionist. V2 stated the rashes are not on the Infection Control log as he didn't know he needed to keep those on the logs and the nurses usually add stuff to the Infection Control log electronically. V2 stated he only keeps infections treated with antibiotics on the log. V2 was asked how he tracks the rashes if they are not on the log and he replied good point. On 11/1/2024 at 10:36AM, V4 (Medical Director) stated he has looked at a couple rashes and one of the resident's (R1) he ordered Permethrin treatment. V4 stated it is kind of a toss-up with R1 and the rash has some characteristics of possibly scabies so that is why I ordered the Permethrin cream. V4 stated he has not had much luck with skin scrapings as it a hit and miss kind of thing. V4 stated even Dermatologist do not do a lot of skin scrapings anymore because they are not always accurate. Sometimes we just treat with Permethrin to see if it makes a difference. One possibility to do when you have numerous rashes is to treat everyone with Permethrin. V4 stated he would be coming to the facility, and he wanted to look at the residents with rashes. On 11/1/2024 at 11:00AM, V5 (Licensed Practical Nurse) stated skin checks should be done daily on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 3 of 11 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 11/12/2024 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 0880 Level of Harm - Actual harm Residents Affected - Few anyone with a rash. V5 stated she knows that they tried different body washes and detergents on R1, and nothing seems to help. V5 stated R1 was the first one she knew of with this rash. V5 stated V15 (Certified Nurse Assistant/CNA) had a rash but the staff member went to the doctor and the doctor stated it was viral. On 11/1/2024 at 2:10PM, V12 (Laundry Staff) stated the facility has not changed laundry soap in a very long time. V12 stated no resident's laundry is being done in special soap at this time. V12 stated 2 weeks ago we did do R1's laundry separate and with a different soap, but we are not doing that anymore. V12 stated she has not seen any signs of bed bugs but was told R1 had scabies, but she didn't know how accurate that information was. On 11/1/2024 at 2:35PM, V4 (Medical Director) entered the facility and checked residents with rashes. V4 met with V2 (Director of Nursing) and this surveyor and stated he feels R1, R2, R3, R4 and R5 need to be treated with Permethrin because R1 was treated and has shown improvement and he wants her treated again. V4 stated there are characteristics of scabies but he would not do scrapings as those are never definite. V4 stated with rashes that have spread through the facility, then treatment of Permethrin is not harmful to the residents, it is best to treat and monitor and if the rashes improve then we know we did the right treatment. V2 stated he felt like at this time it is best to treat just the ones with rashes and that he would conduct a complete skin check of everyone and anyone else with a rash will be included in the treatment plan. V4 stated the beds linens and clothing would also need to wash in hot water and dried in a hot drier. V2 stated he understood. On 11/1/2024 at 9:48AM, R1 was observed lying in bed scratching upon entering room. R1 was scratching her arms, chest and abdomen. V2 (Director of Nursing) at bedside. A rash to R1's arms, chest, abdomen and back were observed. There were small areas with tiny scabs noted on R1's arms, chest, back, and abdomen with linear lines noted between some of the small areas. Scratch marks were also observed mostly to both sides of R1's back with bleeding noted. There was blood noted under R1's fingernails. R1 is alert with confusion noted. On 11/1/2024 at 11:30AM, R1 was observed walking up and down the halls and was scratching her arms and chest. R1 was observed with a grimace on her face as she was scratching her arms. Blood was observed to R1's arms, fingertips, and under fingernails. On 11/7/2024 at 12:50PM, V2 was observed assessing R1 and R1's rash was observed to be improved from 11/1/2024. V2 stated the linear lines are even faded away. There was no bleeding noted or scratching upon observation. R1 was observed sleeping upon entering the room. R1's Progress Notes document the following: 9/18/2024: rash all over, itching and crying. Prednisone 20mg x 2 days then 10mg x 4 days. Benadryl 25mg every 6 hours as needed. 10/3/2024: Prednisone 10mg x 3 days, wash laundry in hypoallergenic soap, if not cured make appointment to office for biopsy. 10/11/2024 at 2:09PM: (V3 Medical Doctor) sent referral to (name of local dermatology office). 10/11/2024 at 1:39PM: Resident red scabs all over torso, face, arms, and thighs. Resident continues to scratch herself all over and crying while lying in bed. Residents' appetite poor due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 4 of 11 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 11/12/2024 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 0880 discomfort. Orders to discontinue Remeron and increase Prednisone to 40mg daily x 4 days then 20mg every day for 4 days then 10mg every day for 8 days and 5 mg for 8 days. Level of Harm - Actual harm Residents Affected - Few 10/16/2024 at 10:20 AM: spoke with (V4 Medical Director) regarding resident being itchy all over body. Ordered Permethrin 5% cream to body for 8 hours. 10/18/2024: order with Prednisone titrate has to be restarted due to pharmacy sending card with medications tonight, unaware of why card was sent tonight when order was obtained 10/11/2024. Order restarted so that resident can receive all proper doses per physician instructions 40 mg everyday x 4 days, 20mg everyday x 8 days, 10mg everyday x 8 days, 5mg everyday x 8 days. 10/24/2024 at 7:18 AM: Prednisone 20mg daily x 4 days. 11/1/2024: Permethrin Cream ordered per (V4). 1st application upon receipt from pharmacy. Shower the following day. Repeat process in 1 week. POA (Power of Attorney) aware. 11/5/2024: Prednisone again 20mg x 8 days. R1's weekly skin checks titled Skin Check Weekly and PRN (As Needed) document the following: 9/17/2024: rash all over arms, legs, and back (not new). 9/23/2024: red non raised rash chest. 9/30/2024: red rash over torso, arms, and legs. 10/14/2024: rash all over body. 10/22/2024: rash and scratch marks all over body. R1's Treatment Administration Record (TAR) dated 10/1/24-10/31/24 documents the administration of Permethrin cream on 10/16/24. R1's Physician's Note authored by V3 (Physician) and dated 10/24/24 documents Has had a rash but It has Improved quite a bit. The same note further documents The patient has only faint areas of previous excoriation on the upper arms and chest. No active rash. She is finishing Prednisone now. R1's TAR dated 11/1/2024-11/30/2024 documents the administration of Permethrin cream on 11/1/2024. 2. R2's admission Record documents an admission date of 4/25/2022 and includes diagnoses of Dementia, Alzheimer's Disease, Anxiety, and Depression. R2's MDS dated [DATE] documents a BIMS score of 99, indicating that R2 was unable to complete the interview. On 11/1/2024 at 10:20AM, R2 was noted sitting up in a Geriatric Chair in her room with V7 (family member) at bedside. R2 was observed scratching her arms and chest. R2 had small, scabbed areas all over her arms and upper chest. R2 was unable to answer any questions asked. R2's Progress Notes documented the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 5 of 11 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 11/12/2024 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 0880 11/1/2024 at 10:21 AM: husband noted rash. V4 notified and ordered Prednisone. Level of Harm - Actual harm 11/1/2024 at 5:57 PM Permethrin Crème ordered. Residents Affected - Few 11/3/2024 at 1:36AM: Permethrin creme applied. On 11/7/2024 at 11:06 AM, V7 (family member) stated R2 received the treatment on Saturday night, and she is much better now, and the itching has subsided, and the rash is improving except under R2's arms and he understands those are hard places to reach. V7 stated you can see the areas that were not covered with the treatment. While in R2's room V2 told V7 that R2 would receive a second treatment and they will make sure and get those areas covered better with the treatment. V7 was appreciative and stated he is just glad she is getting better as she was miserable. V2 stated her rash is much improved since the treatment of Permethrin. 3. R3's admission Record documents an admission date of 2/10/2024 and includes diagnoses of Alzheimer Disease, Hypoglycemia, Diabetes Mellitus type 2, Major Depressive Disorder, and Anxiety. R3's MDS dated [DATE] includes a BIMS score of 00, indicating R3 has severe cognition impairment. On 11/1/2024 at 9:50AM, R3 was assessed by V2 (Director of Nursing) and an observation of a rash was noted to arms and abdomen with worse rash noted to left arm. R3 observed scratching the left arm with slight bleeding noted. All areas with small scabs and linear lines were noted between some of the areas to the abdomen. The lines were noted to be shiny in color in the light. There are red bins inside room and protective equipment in the bins outside the door of R3's room. V2 stated that R3 is on Enhanced Barrier Precautions (EBP) due to R3 having a wound. R3's Progress Note dated 11/1/2024 at 5:57 PM, documents orders for Permethrin Creme. R3's November 2024 TAR documented the order for Permethrin cream and was initialed as being administered on 11/1/2024. On 11/7/2024 at 12:51PM, R3 was observed being assessed by V2 and improvement was noted to the rash. V2 asked if R3 was still itching and R3 stated No but R3 was observed to have some confusion. V2 stated her rash is finally fading away. There was no further scratching observed. The Midnight Census Report dated 11/1/24 documents that R3 resides in the same room as R1. 4. R4's admission Record documents an admission date of 11/1/2022 and includes diagnoses of Unspecified Dementia, Alzheimer Disease, Anxiety, and Anemia. R4's MDS dated [DATE] documents a BIMS score of 00, indicating R4 has severe cognition impairment. On 11/1/2024 at 10:22 AM, R4 was observed sitting up in a wheelchair scratching her arms and both arms were noted to have small scabs and open areas noted with some linear marks along with scratch marks. The areas were noted to have some bleeding with blood noted under fingernails. R4 is confused and was unable to answer any questions. On 11/1/2024 at 12:10PM, V2 said he was not aware of R4 having a rash to her arms. R4's document titled Treatment Administration Record dated 11/1/2024-11/30/2024, documents Permethrin Creme was administered on 11/1/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 6 of 11 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 11/12/2024 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 0880 On 11/7/2024 at 12:55PM, V2 was observed assessing R4's rash. R4's rash was observed to be fading and no scratching noted. V2 stated she is much improved. Level of Harm - Actual harm The Midnight Census Report dated 11/1/24 document that R2 and R4 reside in the same room. Residents Affected - Few 5. R5's admission Record documents an admission date of 8/14/2014 and includes diagnoses of Alzheimer Disease, Anxiety, Unspecified Dementia, Major Depressive Disorder, and Hypertension. R5's MDS dated [DATE] includes a BIMS score of 00, indicating R5 has severe cognitive impairment. On 11/1/2024 at 2:35 PM, V4 was observed assessing residents including R5. R5 had a rash observed to arms, abdomen and back, arms are noted to be the areas with scratches and bleeding. Several scattered scabbed areas noted to R5's abdomen, back, and arms. R5's TAR dated 11/1/2024-11/30/2024 documents Permethrin cream was administered on 11/1/2024. On 11/7/2024 at 9:33AM, V2 stated a skin scraping was done on R5 and sent to the local hospital. V2 stated the scraping was done by V4 (Medical Director). V2 stated he scraped 3 separate areas. V2 stated he has called the local hospital to see if the results were back and they were not completed yet as it was a send out specimen and can take up to 6 days to get the results. V2 stated R5 did not receive the Permethrin cream treatment until 11/4/2024 due to waiting on scrapings of skin. On 11/7/2024 at 12:58PM, V2 was observed assessing R5 right after a shower. A rash was observed to R5's arms and abdomen and are still red in color with scabs noted. V2 stated R5 did not get treated with Permethrin until 11/4/2024 due to waiting until after skin scrapes were completed. R5's room was not observed to have any isolation bins or signs posted. On 11/8/2024 at 1:05PM, V2 stated he just checked, and the lab reported to him that R5's lab requisition was filled out wrong as the diagnosis on the requisition had rash instead of scabies and the wrong stain was used but it would be run to see if it will result. On 11/11/2024 at 2:48PM, V2 stated he still did not have results from the lab. V2 was asked about R5's Treatment Administration Record documenting the Permethrin cream being administered on 11/1/2024 which was before the scrapings were obtained. V2 stated I don't know why they did that and maybe they charted it wrong but V2 stated he would look into that matter. V2 stated we held R5's Permethrin treatment for the reason of getting the scrapings so the results would be more accurate. R5's lab report with a print date of 11/11/24 documents that the specimen received was a skin scraping from the abdomen and ordered test was a fungal stain with no fungus observed. There were no ordered test or results for a skin scraping to detect scabies documented on R5's lab report. 6. R6's admission Record documents an admission date of 12/4/2019 including diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Legal Blindness, Dysphagia, and Depression. R6's MDS dated [DATE] includes a BIMS score of 00, indicating R6 has severe cognition impairment. On 11/7/2024 at 9:33AM, V2 stated they completed the 100 % skin audit on all residents and added 2 more residents, R6 and R7, to the list of residents having rashes. V2 stated that R6 and R7 were added to the list for treatment with Permethrin. R6's Progress Note dated 11/1/2024 documents orders for Permethrin 5% cream. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 7 of 11 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 11/12/2024 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 0880 R6's TAR dated 11/1/2024-11/30/2024 documents Permethrin cream was administered on 11/1/2024 at 8:00PM. Level of Harm - Actual harm Residents Affected - Few On 11/7/2024 at 12:45 PM, V2 stated R6 received Permethrin treatment and R6's rash looks much better now. A rash was observed to R6's abdomen and arms with noted scattered small scabs. No scratching noted. 7. R7's admission Record documents an admission date of 12/29/2017 and includes diagnoses of Anxiety Disorder, Unspecified Dementia, Dysphagia, Anorexia, Anemia and Hypertension. R7's MDS dated [DATE] documents a BIMS score of 00, indicating R7 has severe cognitive impairment. R7's TAR dated 11/1/2024-11/30/2024 documents that Permethrin cream was administered on 11/1/2024. On 11/7/2024 at 12:47PM, V2 was observed assessing R7 and a rash was noted to R7's abdomen, arms and back. R7's rash was observed to have tiny scabs on both arms. V2 stated that R7 has received the Permethrin cream treatment as well. V2 stated R7's rash looks much better now. The Midnight Census Report dated 11/1/24 documents that R5 and R7 reside in the same room. On 11/7/2024 at 11:12AM, V2 was asked if any of the residents were separated due to rash and he stated No because all the ones with a rash had a roommate with the rash except one and that resident is in a room by himself. On 11/7/2024 at 11:26AM, V4 (Medical Director) stated with the improvement of the rashes I believe we are heading in the right direction. V4 stated he ordered for the residents to have a second treatment in a week to make sure all areas get treatment applied and to make sure this is taken care of. On 11/7/2024 at 12:00PM, V2 stated none of the residents with rashes were placed on Contact Isolation. V2 stated he instructed the staff to send all the clothes that the residents had on and the bed linens to laundry to be washed separately and in hot water. V2 stated none of the residents' clothes in their closest was rewashed or bagged up. On 11/7/2024 at 1:08PM, V15 (Certified Nurse Assistant/CNA) stated she had a rash, but it wasn't the same as what the residents have, and her doctor stated her rash was from a virus. V15 stated the residents have had this rash for more than a week that she knows of. V15 stated she was aware of 2 staff CNA's that had the same rash as the residents, but they no longer work there. V15 stated they have been gone for a couple of weeks now. V15 stated we had another resident with a rash, but she has passed away. V15 stated she worked this past weekend on 11/2/24 and 11/3/2024 and none of the residents were on Contact Isolation precautions and we were not told to bag or separate their laundry. V15 stated I have noticed this rash is spreading around the facility and there are 2 halls now with residents with rashes. On 11/7/2024 at 1:15 PM, V8 (Laundry) stated she did not work this past weekend. V8 stated R1's clothes were separated 2-3 weeks ago before her treatment, she believes it was before the 18th of October. V8 stated she worked on 11/4/2024 and there was no separate laundry for any of the resident and has not been this week. V8 stated she was told a few weeks back that R1 had scabies and that was why we was doing her laundry separate. On 11/7/2024 at 1:34PM, V16 (Licensed Practical Nurse) stated the rashes she has seen have been on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 8 of 11 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 11/12/2024 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 0880 Level of Harm - Actual harm Residents Affected - Few the residents' arms and torso and some of the residents were scratching and scratching bad. V16 stated Permethrin cream was applied on the night shift. V16 stated she was not aware of any staff with rashes. V16 stated skins checks are being done either daily or weekly on the ones with a rash. V16 stated she does her skin checks on shower days which are twice a week. V16 stated there was another resident with a rash but she passed away a while back. On 11/7/2024 at 2:11PM, V12 (Laundry) stated she worked 11/2/2024 from 6AM to 6PM and she did not do any laundry separate or was told to do anything extra like hot water or dry clothes on high heat. V12 said the only laundry done separate is the ones on Enhanced Barrier Precautions and they have been doing those for a while. V12 stated that is the only laundry received in red bags. V12 stated R2, R4, R5, R6 and R7's clothes were done as normal with everyone else's. V12 stated R1 and R3's clothes are always in a red bag together as R3 is on Enhanced Barrier Precautions and they just wash those 2 together as they are roommates. On 11/7/2024 at 2:25PM, V18 (Licensed Practical Nurse) stated she worked Saturday 11/2/2024 from 6AM to 6PM and she knew the treatment had not been done yet as the medicine had not been delivered yet. V18 stated no residents were on Contact Isolation precautions that she was aware of. V18 stated she was not aware that the clothes and bed linens had to be washed in hot water after the treatment either. V18 stated she knows R1 and R3's laundry is always done together as R3 is on Enhanced Barrier Precautions for a wound. On 11/7/2024 at 2:43 PM, V19 (Licensed Practical Nurse) stated she was not sure what the rashes are, but she did work this past weekend 11/2/2024 and 11/3/2024 6AM-6PM. V19 stated the treatments were done on 11/2/2024 on the night shift. V19 stated nobody receiving the treatment was on Contact Isolation except R1 and R3 and they are on precautions for Enhanced Barrier Precautions for a wound on R3 and they are roommates. V19 stated she wasn't aware of any laundry on the others being done separately or with hot water. On 11/7/2024 at 3:30PM, V20 (Laundry and Housekeeping Supervisor) stated she worked on Sunday 11/3/2024. V20 stated she was working in laundry and there were no isolation bags that had come to laundry on 11/3/2024. V20 stated there were no instructions given to us about washing anything in hot water and high dryer heat. V20 stated the beds for R2, R4, R5, R6, and R7 were not stripped and sent to laundry either. V20 stated the beds would have needed to be cleaned thoroughly too but they were not done as they were not instructed to do so. V20 stated for a while they were doing R1's laundry in a special soap and separate from others but we haven't done that in a while. The facility Infection Surveillance Monthly Report dated 11/1/24 documents for R2 and R5 under the Other Infection Category with an infection onset date of 9/30/24. Under Status it documents closed (10/8/24)-resolved There is no documentation or description of what type of infection that R2 or R5 had on the report. There is no documentation of R1, R3, R4, R6, or R7 on the Infection Surveillance Monthly Report of having an infection under the Other Infection Category or Skin and Soft Tissue Infection Category. The facility policy titled Surveillance for Infections (revision date September 2017) documents that the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 3. Infections that will be included in routine surveillance include those with: d. Pathogens associated with serious outbreaks (e.g., invasive Streptococcus Group A, acute hepatitis, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 9 of 11 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 11/12/2024 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 0880 norovirus, scabies, and influenzas.) Level of Harm - Actual harm The facility policy titled Scabies Identification, Treatment and Environmental Cleaning (revision date August 2016), documents under General Guideline, 6. Scabies is spread by skin-to-skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. 7. Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings, although scrapings are preferred. 8. Affected residents should remain on Contact Precautions until 24 hours (24) after treatment . 11 . A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved. 12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing as established by the facility's infection and exposure control programs. Under the section titled Environmental Control: Typical Scabies it documents 1. Place residents with typical scabies on contact precautions during the treatment period; 24 hours after application of 5% permethrin cream or 24 hours after last application of scabicides requiring more than one application .4. Place bed linens, towels and clothing used by an affected person during the 4 days prior to initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for at I0-20 minutes. 5. Use the hot cycle of the dryer for at least I0-20 minutes. 6. Place non-washable blankets and articles in a plastic bag for at least 72 hours. These items can also be dry cleaned or tumbled in a hot dryer for 20 minutes. 7. Change all bed linens, towels and clothes daily. 8. Disinfect multiple residents-use items, such as walking belts, blood pressure cuffs, stethoscopes, wheelchairs, etc., before using on other residents. 9. Discard all creams, lotions or ointments used prior to effective treatment. I0. Vacuum mattresses, upholstered furniture and carpeting. Wrap vacuum cleaner bag in a plastic bag and discard. a. General cleaning and thorough vacuuming of furniture, mattresses or rug is recommended. b. Fumigation is not necessary. 11 . For non-fabric items, routine disinfection procedures are adequate. Residents Affected - Few The facility policy titled Isolation- Initiating Transmission-Based Precautions (revision date October 2018) documents 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor notifies the Infection Preventionist and the resident's Attending Physician for evaluation of appropriate Transmission-Based Precautions. The Center for Disease Control (CDC) website (https://www.cdc.gov/scabies/php/public-health-strategy/index.html) documents under the section titled Prevention that Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). New patients/residents and employees should be screened carefully and evaluated for any skin conditions that could be compatible with scabies . When there is concern for scabies in a person, skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Appropriate isolation and infection control practices (e.g., gloves, gowns, avoidance of direct skin-to-skin contact, etc.) should be used when providing hands-on care to patients/residents who might have scabies. Epidemiologic and clinical information about patients/residents with confirmed and suspected scabies should be collected and used for systematic review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 10 of 11 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 11/12/2024 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 0880 in order to facilitate early identification of and response to potential outbreaks. Level of Harm - Actual harm The Midnight Census Report dated 11/1/24 documents that there are 41 residents that reside in the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146175 If continuation sheet Page 11 of 11