F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the facility failed to provide the services of a Registered Nurse for 8
consecutive hours per day seven days per week. This failure has the potential to affect all 42 residents living
in the facility.
Findings Include:
On 04/10/25 at 9:57AM V6 (Licensed Practical Nurse/LPN) stated that most of the time the facility does
have a Registered Nurse for 8 consecutive hours a day seven days a week. V6 stated that V2 (Director of
Nursing/DON) usually works Monday-Friday, and he covers the Registered Nurse coverage during the
week. V6 stated that V4 (Registered Nurse/RN) works every other Saturday on the floor. V6 stated that she
doesn't think that they have Registered Nurse coverage on Sunday's.
On 04/10/25 at 11:40AM V7 (LPN) stated that the facility does not have Registered Nurse coverage 8
consecutive hours a day seven days a week. V7 stated that on her weekend that she works there in no
Registered Nurse coverage on Saturday or Sunday. V7 stated that her next weekend to work is on 04/12/25
and 04/13/25. V7 stated that V4 (RN) does not work her weekend either day.
On 04/10/25 at 11:45AM V5 (LPN) stated that V2 (DON) has worked a couple of Saturdays along with V4
(RN). V5 stated that the facility does not have RN coverage for 8 consecutive hours seven days a week.
On 04/10/25 at 12:30PM V1 (Administrator) stated that the facility does not have RN coverage for 8
consecutive hours seven days a week. V1 said that V2 (DON) and V4 (RN) do try to cover the floor often for
the RN coverage, but they do have days that are not covered. V1 stated the facility is working on obtaining
RN coverage for 8 consecutive hours seven days a week. V1 stated they are trying to hire more RN's at this
time.
Review of the Nursing Schedule from 02/26/25-04/09/25 documents no RN coverage was provided at the
facility on 03/01, 03/02, 03/09, 03/15, 03/16, 03/23, 03/29, 03/30, and 04/06.
The facility policy titled Staffing (undated) documents under policy interpretation and implementation 1.
Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care
services. RN coverage will be provided 8 hours per day, 7 days per week. If RN coverage is not available for
direct care staffing, LPN will cover with RN on call to assess and assist as needed.
The Resident List Report dated 04/07/25, documents there are 42 residents living in the facility.
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 2
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
04/10/2025
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide at least 80 square feet per resident in
multiple occupancy resident bedrooms for 4 of 4 residents (R5, R9, R31, R35) reviewed for room size in a
sample of 32 .
Findings include:
Observation on 4/09/25 at 11:20AM revealed R31 and R9 shared a bedroom. It was a smaller sized
bedroom with two beds, two nightstands, two over the bed tables, a regular sized wheelchair, and one
reclining massage chair 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.
Observation on 04/09/25 at 11:35AM revealed R35 and R5 shared a bedroom. It was a smaller sized
bedroom with two beds, two nightstands, two over the bed tables, one wheelchair, a reclining massage
chair 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 V8 (Maintenance Supervisor) on 04/09/25 at 11:20AM, V8 was asked to measure R31,
R9, R35 and R5's bedroom sizes. V8 used a measuring tape to measure the length and width of R35 and
R5's bedroom and stated, 12.5 [feet] by 12 [feet] [which was equivalent to 150 square feet/75 feet per
resident bed]. The measurement did not include the closet or built in dresser area. At approximately
11:35AM, V8 measured R31 and R9's bedroom and stated, 12.5 [feet] by 12 [feet] [which was equivalent to
150 square feet/75 feet per resident bed]. The measurement did not include the closet or built in dresser
area.
During an interview on 04/09/25 at 11:45AM with V3 (Director of Nursing), 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 04/09/25 at 11:45AM, V1 (Administrator) stated that all rooms on A hall and B hall do not meet the
requirement of having 80 square feet per resident. V1 verified those rooms included 1-10, 20-28 and rooms
[ROOM NUMBERS]. V1 stated that all residents are notified upon admission of the room sizes. V1 stated
that all the rooms on A and B hall that don't meet the requirement for 80 square feet are dually certified for
Medicare or Medicaid residents.
On 04/09/25 at 12:00PM, R31 and R9 both stated they had no problems with their rooms and had enough
space in their rooms.
On 04/09/25 at 12:30PM, V11 (Family Member) stated that R35 has no problems with the size of his room
and that she thinks that they have enough space in the room. V11 said that R35 is in a wheelchair and staff
must use a mechanical lift on him to get him out of the wheelchair and bed and they have no problems with
using the mechanical lift in the room.
Facility Floor Plan provided by the facility documents rooms 1-10, 20-28 and rooms [ROOM NUMBERS]
are all waivered rooms for size.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146175
If continuation sheet
Page 2 of 2
