Pinckneyville Nursing & Rehab

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews. Several staff members, including Licensed Practical Nurses (LPNs) and the Administrator, confirmed that RN coverage was inconsistent, particularly on weekends. The Director of Nursing (DON) and another RN attempted to cover the required hours, but there were days without RN coverage. The facility's nursing schedule from late February to early April documented multiple days without RN coverage. The facility's policy mandates RN coverage for 8 hours daily, 7 days a week, with LPNs covering in the absence of an RN, who would be on call. However, the policy was not adhered to, as evidenced by the lack of RN coverage on specific dates. The Administrator acknowledged the issue and mentioned efforts to hire more RNs to meet the requirement. This deficiency has the potential to affect all 42 residents living in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for four residents. Observations revealed that two pairs of residents shared bedrooms that measured 150 square feet in total, equating to only 75 square feet per resident. These measurements were confirmed by the Maintenance Supervisor, who used a measuring tape to assess the room dimensions. The rooms did not include the closet or built-in dresser areas in the measurements, which did not affect the living area. The Director of Nursing acknowledged the requirement for two-resident bedrooms to have over 80 square feet per resident. The facility's Administrator confirmed that all rooms on A and B halls do not meet the 80 square feet per resident requirement, affecting rooms 1-10, 20-28, and other specified rooms. These rooms are dually certified for Medicare or Medicaid residents, and residents are notified of the room sizes upon admission. Despite the deficiency, residents and a family member expressed no issues with the room sizes, stating there was enough space for their needs, including the use of a mechanical lift for a resident in a wheelchair. The facility's floor plan indicates that these rooms are waivered for size.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement effective surveillance measures to detect, treat, and prevent the spread of a potential scabies infestation among its residents. This deficiency was identified through interviews, observations, and record reviews, revealing that seven out of nine residents reviewed for infection control were affected. The failure to properly address the issue resulted in one resident experiencing intense itching for over a month, leading to distress, crying, facial grimacing, and a loss of appetite. The potential scabies infestation was not documented on the facility's Infection Control log, as the Director of Nursing, who also served as the Infection Preventionist, was unaware that such rashes needed to be included. The facility's Director of Nursing admitted that a 100% skin audit had not been conducted on all residents, and none had been seen by a dermatologist. The Medical Director had ordered Permethrin treatment for some residents, suspecting scabies, but no skin scrapings were performed to confirm the diagnosis. The facility's policy required that residents with scabies be placed on contact precautions, but this was not done. Additionally, the facility failed to follow proper procedures for handling potentially contaminated laundry, as residents' clothes and bed linens were not washed separately or in hot water as required. The report highlights that the facility's Infection Surveillance Monthly Report did not document the rashes as infections, and the facility's policies on scabies identification, treatment, and environmental cleaning were not followed. The Center for Disease Control (CDC) guidelines emphasize the importance of early detection, treatment, and appropriate isolation and infection control practices to prevent scabies outbreaks. However, the facility did not adhere to these guidelines, resulting in the spread of rashes among residents and staff, with some staff members having left the facility due to similar rashes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow physician's orders for a resident with severe cognitive impairment, leading to a deficiency in care. The resident, who was admitted with diagnoses including Anxiety, Anorexia, Hyperlipidemia, Alzheimer's Disease, and Dementia, had a care plan addressing a risk for alteration in skin integrity. The care plan included medication for itching and a referral to a dermatology clinic. Despite these orders, the resident continued to experience severe itching and a rash, as documented in progress notes and observed by staff. The resident was seen scratching her arms, chest, and abdomen, with visible rashes, scabs, and bleeding under her fingernails. The deficiency arose from a miscommunication regarding the execution of the physician's orders. Although a referral to a dermatology clinic was documented, the resident never attended the appointment. The Director of Nursing was unaware of the referral and biopsy orders, indicating a breakdown in communication and follow-through. The resident's condition, including the need for a biopsy if the rash persisted, was not addressed, resulting in ongoing discomfort and potential harm. This lack of coordination and adherence to the care plan highlights the facility's failure to provide appropriate treatment and care according to the resident's needs and physician's directives.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from peer-to-peer sexual abuse, involving a resident with a history of inappropriate sexual behavior. This resident, who was admitted with diagnoses including Alzheimer's Disease and moderate cognitive deficits, engaged in unwanted sexual contact with three other residents who were cognitively impaired and unable to consent. The incidents included touching residents' breasts and making unsolicited sexual comments. Despite being aware of these behaviors, the facility did not implement effective supervision or monitoring to prevent further incidents. The first incident occurred when the resident touched another resident's breast, which was witnessed by a Licensed Practical Nurse. Although the residents were separated immediately, the facility did not establish a plan for effective supervision. Subsequent incidents involved the same resident grabbing another resident's breast and making sexual comments to a third resident. These incidents were reported, but the facility's response was inadequate, as the resident continued to exhibit inappropriate behaviors without sufficient monitoring or intervention. The facility's records indicate that the resident was placed on 15-minute checks, but documentation was inconsistent, and there was no evidence of one-to-one monitoring. Staff reported being unable to adequately supervise the resident due to staffing shortages. The facility's failure to implement and maintain effective interventions allowed the resident to continue engaging in inappropriate behaviors, posing a risk to other residents.

Removal Plan

• The Facility has implemented and educated staff on its Abuse Policy, including effective, individualized interventions for all residents displaying inappropriate sexual behavior.
• All staff and department heads have been educated to ensure if there are reports of inappropriate sexual behaviors, they are to be immediately reported to their Administrator and individualized interventions need to be put in place to prevent further altercations. Education was provided by the Director of Operations and Regional Clinical Director. All licensed staff will be educated prior to their next shift. This will be reviewed and verified by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide reeducation if deficiencies are recognized. All audits and verifications will be provided to QA team.
• The facility has incorporated effective monitoring of residents with sexually inappropriate behaviors to ensure all residents remain free of resident to resident abuse.
• R1 was discharged to a Regional Hospital. Education for effective monitoring of inappropriate behaviors was provided by the Director of Operations and Director of Nursing. All staff will be educated prior to their next shift. This will be reviewed and verified by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide re-education if deficiencies are recognized. All audits and verifications will be provided to QA team.
• All reportables have been reviewed to ensure there are effective interventions in place and care plans are updated.
• R2, R3 and R7 have all had trauma assessments completed and psycho-social follow-up. No negative results noted.
• This will be reviewed and verified by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide re-education if deficiencies are recognized. All audits and verifications will be provided to QA team.
• The QA team was notified of the Immediate Jeopardy and the abatement plan that was put into place. The QA team will review the results of the audits, as referenced above, to ensure the plan of correction is effective.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the representatives of two residents about incidents of peer-to-peer sexual abuse. One resident, who was admitted with diagnoses including unspecified dementia and diabetes type 2, was involved in an incident where another resident attempted to lift their shirt. This incident was witnessed by a Licensed Practical Nurse (LPN) but was not reported to the resident's Power of Attorney (POA) or the facility's administrator, who is also the abuse coordinator. Consequently, an abuse investigation was not initiated, and the resident's representative was not informed. In another incident, a resident with severe cognitive impairment was subjected to inappropriate behavior by a male resident who was unclothed and masturbating with the door open. This resident was beckoned to engage in sexual activity, which visibly upset them. A Certified Nursing Assistant (CNA) witnessed the incident and reported it to a charge nurse, but there was no documentation of the incident in the resident's chart, nor was the responsible party notified. The facility's abuse coordinator confirmed that the incident was not reported to her, and therefore, the resident's representative was not informed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report incidents of peer-to-peer sexual abuse involving three residents to the Administrator, who is also the facility's Abuse Coordinator. In one incident, a Licensed Practical Nurse (LPN) witnessed a resident attempting to lift another resident's shirt at the nurse's station. Despite observing this behavior, the LPN did not report the incident to the Administrator, and no abuse investigation was initiated. The resident involved in this incident had a history of inappropriate behaviors, including exposing himself and making inappropriate comments, as documented in his care plan. In another incident, a Certified Nursing Assistant (CNA) observed a resident lying unclothed on his bed, masturbating with the door open, and making sexual comments to another resident passing by. The CNA redirected both residents and informed a charge nurse, but the incident was not reported to the Administrator. The residents involved in these incidents had cognitive impairments, with one being moderately impaired and the other severely impaired. The facility's Abuse Prevention Policy requires staff to report any incidents or suspicions of abuse immediately to the Administrator, which was not followed in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide effective behavioral interventions for a resident, identified as R1, who exhibited inappropriate sexual behaviors towards other residents and staff. R1, who was admitted with diagnoses including Alzheimer's Disease and Adjustment Disorder, displayed moderate cognitive deficits and was ambulatory. The incidents began shortly after R1's admission, with the first reported incident involving unwanted contact with another resident, R2. Despite being separated and assessed, R1 continued to exhibit inappropriate behaviors, including touching another resident, R3, and making sexually inappropriate comments and gestures towards staff. The facility's response to R1's behaviors included medication adjustments and increased supervision orders, such as 15-minute checks. However, documentation revealed significant lapses in the implementation of these interventions, with numerous instances of missing documentation for the 15-minute checks. Staff interviews indicated that R1 was not consistently monitored as required, and there was a lack of sufficient staffing to provide the necessary one-to-one monitoring. Staff members reported feeling unable to adequately protect other residents from R1's behaviors due to these staffing challenges. The facility's Behavioral Assessment, Intervention, and Monitoring Policy required immediate safety strategies to protect residents from harm, but the report indicates that these measures were not effectively implemented. R1's behaviors continued to escalate, leading to multiple incidents of inappropriate contact with other residents and staff. The facility's failure to provide adequate supervision and intervention for R1's behaviors resulted in a deficiency in ensuring the safety and well-being of all residents.

Penalty

Inspection fine: $135,805

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient staffing to meet the needs of its 45 residents, particularly in ensuring that residents received showers and assistance with care. Observations and interviews revealed that residents often experienced delays in receiving help, especially at night, and some residents, like R5, had to attempt transfers without assistance, leading to falls. The documentation showed that scheduled showers were frequently missed or not recorded for multiple residents, including R5, R4, R6, and R7, indicating a systemic issue with staffing and care provision. Interviews with staff and residents highlighted the severity of the staffing shortage. A Licensed Practical Nurse (LPN) and several Certified Nursing Assistants (CNAs) reported that the facility was often operating with only two or three CNAs, which was insufficient to meet the needs of residents, many of whom required total assistance with activities of daily living (ADLs) and had behaviors necessitating one-on-one supervision. The staff expressed that they were stretched thin, with some CNAs working alone in heavy workload areas and struggling to complete their duties, including providing showers and timely incontinence care. The facility's administration acknowledged the staffing issues, with the Administrator and Social Services Director frequently assisting on the floor. However, the Director of Nursing (DON) was noted to be less involved in direct care. The facility's wages were reportedly not competitive, contributing to difficulties in attracting and retaining staff. The lack of a specific policy for handling call-ins further exacerbated the staffing challenges, leading to instances where only one or two CNAs were available for extended periods, as documented in the nursing and CNA schedules.

Penalty

Inspection fine: $135,805

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely assistance with Activities of Daily Living (ADL) for five out of seven residents reviewed. Residents were not receiving scheduled showers, and there was a lack of documentation for showers or refusals on multiple occasions. For instance, one resident, who is totally dependent on staff for ADLs, had no documentation of showers or refusals for several scheduled days. Another resident, who is cognitively intact but requires assistance with transferring, reported not receiving showers as scheduled and experienced a fall while attempting to transfer independently due to delayed staff response. The report highlights staffing shortages as a significant issue contributing to the deficiency. Interviews with staff and family members revealed that the facility was often short-staffed, with only a few CNAs available to assist residents. This shortage led to delays in responding to call lights and providing necessary care, such as transferring assistance and incontinence care. Staff members, including the administrator and social services director, were observed assisting on the floor, but the shortage persisted, impacting the quality of care provided. Family members expressed concerns about the lack of staff and the impact on resident care, noting instances where residents were left in wet clothing for extended periods. Staff interviews confirmed the challenges faced due to insufficient staffing, with CNAs struggling to complete their duties and maintain proper documentation. The facility's policy requires documentation of shower refusals and interventions, but this was not consistently followed, contributing to the deficiency in care.