Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to initiate the process to timely obtain a prescription
medication for 1 of 3 residents (R1) reviewed for medications in the sample of 7.This past noncompliance
occurred from 7/27/25 and 7/28/25.Findings include:R1's admission Record documents an admission date
of 6/20/25, a discharge date of 7/28/25, and listed diagnoses including hypertension, chronic obstructive
pulmonary disease (COPD), unspecified, other cerebral infarction due to occlusion or stenosis of small
artery, other specified symptoms and signs involving the circulatory and respiratory systems, bradycardia,
unspecified, cerebral infarction, unspecified, and peripheral vascular disease.R1's Minimum Data Set
(MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 4, indicating that R1
had severe cognitive impairment.R1's Care Plan documented R1 had COPD and a history of a recent
Cerebral Vascular Accident (Stroke). Both focus areas have interventions including giving medications as
ordered by the physician.R1's Physician's Order Sheet documented an order for Diltiazem HCI
(hydrochloride) Oral Tablet 120 MG (Diltiazem HCI) Give 3 tablets by mouth one time a day for a fib (Atrial
fibrillation), hold if pulse under 70. This order documented a start date of 7/27/26.R1's Medication
Administration Record (MAR) for July 2025 documented on 7/27/25, R1 was administered Diltiazem HCI
Oral Tablet 360mg by V4 (Licensed Practical Nurse/LPN), the area where the pulse is to be recorded is
marked n/a. On 7/28/25, this MAR further documents that R1 was not administered her dose of Diltiazem
because she was hospitalized .R1's Progress Notes document on 7/28/25 at 9:13am, CNAs (Certified
Nursing Assistants) alerted this nurse that resident is SOB (Short of Breath). Upon entering room, resident
appears to have labored breathing. O2 (oxygen) at 87% on 3L (Liters) via nasal cannula. Pulse irregular,
jumping from 50/60 to 160/170. (Name of Medical Doctor/V5) called at 0834 and gave orders for resident to
be sent to ED (Emergency Department) for further evaluation.R1's medical records from the local hospital
emergency room dated 7/28/25 at 9:35am, documents the following: .Patient complains of palpitations and
shortness of breath that started this morning. Patient was admitted to this hospital Friday for pneumonia
and apparently while on the floor she developed atrial fibrillation with rapid ventricular response. She was
discharged on Saturday with Cardizem ordered for rate control. Apparently, she did not receive it because
the nursing home did not have it available over the weekend. Patient was given Cardizem 15 mg IV
(intravenously) push en route by EMS without the accompanying infusion. She had a normal heart rate
upon arrival however prior to initiation of the Cardizem infusion her ventricular rate increased to the 120s.
She denies any chest pain or fevers .On 8/7/25 at 7:57am, V3 (Licensed Practical Nurse/LPN) stated she
was the nurse that sent R1 to the Emergency Room. She stated she was in the middle of medication pass
when the aides alerted her that R1 was short of breath and her pulse was all over the place. V3 stated she
had not yet administered R1's medications so she went to pull them from the emergency kit and there was
only one pill, and it was 180mg. V3 stated R1's dose was 360mg. V3 stated 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 3
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
08/07/2025
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
went to assess R1 and immediately contacted the doctor and sent her to the emergency room. V3 stated
she was not sure if the emergency kit had been accessed the day before.On 8/7/25 at 8:30am, V4 (LPN)
stated she could not recall how she obtained the medication to administer R1's dose of Diltiazem on
7/27/25 or if she administered it. V4 stated she would not mark that the medication was administered on
7/27/25 unless she gave it. V4 stated if the patient's card was not yet delivered, she would access the
emergency kit. V4 stated if she was not able to obtain a resident's medication, she would contact the
Physician for further instructions or orders.On 8/7/25 at 9:37am, V5 (Physician) stated missing one dose of
Diltiazem can be critical for a patient. V5 stated this medication does not work as effectively as other drugs
of the same class. V5 stated he could not say for sure that it directly caused R1's hospitalization because
R1 was already in bad shape, but this is not a medication that should ever be missed. V5 stated he wasn't
contacted by anyone from the facility about R1 until she was sent to the emergency room on 7/28/25.On
8/7/25 at 10:19am, V8 (Family Member) stated R1 was discharged from the hospital (to the facility) on
Saturday 7/26/25. V8 stated R1 was released while still in A-fib (atrial fibrillation), that was the reason that
her dose was so high. V8 stated when she met R1 at the emergency room (on 7/28/25), the ambulance
driver and the nurse both told her that she had not received the medication since she was previously
discharged . V8 stated they (paramedics) gave her the medication she missed intravenously in the
ambulance and then they gave her another medication. V8 stated when V9 (family member) went to collect
R1's things, two staff members, V1 (Administrator) and V2 (Director of Nursing) both stopped her and
continued to apologize and state that they were so sorry that all of this had happened. V8 stated they
openly admitted they did not give the medication to R1.On 8/7/25 at 11:24am, V6 (Pharmacy Technician)
stated they received an order for R1's medication on 7/26/25 after 1pm, which is when they close, and it
was delivered on 7/28/25 the next business day they were open. V6 stated they have an after-hours back
up pharmacy and if they needed something, they could contact them. V6 stated if staff take something from
the facility emergency kit, there is a log inside of it and the facility is to contact the pharmacy and let them
know they have to refill it. V6 confirmed that there was no communication from the facility regarding this
medication being taken from the emergency kit.On 8/7/25 at 11:44pm, V7 (Pharmacy Supervisor) stated
they do keep Diltiazem in the emergency kit at the facility, but they only keep 180mg because it is not a very
often needed drug and R1's dose was outside of normal dosage. V7 stated R1's dose was 360mg. V7
stated there is a backup pharmacy that the facility can call if they need medications after hours. V7
confirmed there were no call outs to the backup pharmacy that weekend.On 8/7/25 at 11:58am, V2
(Director of Nursing/DON) stated if they did not have a resident's medication in house, the expectation
would be for nursing staff to follow facility protocol on obtaining the resident's medications. V2 stated if
nursing staff were unable to obtain a resident's medication, they should contact the physician.Facility policy
titled, Medication ordering and receiving from the pharmacy, IC5: Emergency pharmacy service and
emergency kits, with an effective date of 06/01/23 documents the following under procedure, The charge
nurse.3) Ascertains whether the ordered medication is contained in the emergency kit by referring to the list
of contents posted on the box. 4) If the medication is not available, calls the pharmacy, using the after-hours
emergency number(s) if necessary .Medications are not borrowed from other residents. The ordered
medication is obtained either from the emergency box or from (Name of Pharmacy), or the third-party
emergency pharmacy.Prior to the survey date, the facility took the following actions to correct the
noncompliance:1. The facility held a QAPI (Quality Assurance and Performance Improvement) meeting on
7/28/25 with V1 (Administrator), V2 (DON), V10 (Medical Director), V11 (Dietary Manager), and V12
(Regional Nurse) in attendance. The facility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146175
If continuation sheet
Page 2 of 3
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
08/07/2025
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
QAPI agenda/meeting template documents 1. Immediate Re-Education with all nursing staff related to
proper MD (Medical Director) notification. 2. Immediate Re-Education with all nursing staff related to the
correct process when medication is not available to give including proper notification to pharmacy of
medication that is needed. 3. A QA tool has been created to monitor effectiveness to ensure compliance to
promote improved quality performance.2. In-service/Education documentation shows that all facility nurses
were educated on change in condition or status-proper MD notification and Pharmacy notification. Hospital
discharge report form to completed by Nurse receiving report on new admit/readmit and given to DON. If
medications are not on hand or available in E-kit, must call pharmacy for E-Run and Notify DON and MD.
This in-service was completed on 7/28/25.3. QA Audit Tool documents daily audits were performed from
7/28-8/5 and will continue through 8/8. Progress notes, 24 hour reports, changes in condition or significant
events noted and physician notification were audited by V1 (Administrator) V2 (DON).
Event ID:
Facility ID:
146175
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the August 7, 2025 survey of PINCKNEYVILLE NURSING & REHAB?
This was a inspection survey of PINCKNEYVILLE NURSING & REHAB on August 7, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PINCKNEYVILLE NURSING & REHAB on August 7, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
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.