Pinckneyville Community Hospital

“On July 21, 2026, the Life Safety Code portion of a Re-Certification Survey was conducted. The surveyor was accompanied during the survey walk-through by the following provider representatives: Director (D) Maintenance Manager (MM) Maintenance Coordinator (MC) The building was constructed in 2015 and was observed to be one story in height. The building was observed to be Type II (222) construction and was fully covered by an automatic sprinkler system. The Hospital was surveyed as an existing health care occupancy under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. An adjoining business occupancy medical building is separated from the health care occupancy by a 2-hour fire barrier. Unless otherwise noted, all deficiencies cited herein were found through direct observation during the survey walk-through, staff interview, or document review. The requirements of 42 CFR Subpart 485.623, Physical Environment, are NOT MET.”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 53451 Based on observation, the 2 hour fire barrier, deemed as a horiontal exit (contains an exit sign above the door), does not form a complete barrier to provide separation for a horizontal exit to a non health care occupancy. Failure to provide required separations can contribute to the spread of fire & smoke and compromise the safety of building occupants. Findings include: On 7/21/2026 at 10:25 am, while in the company of D and MM, it was observed that the required 2 hour separation is incomplete between the hospital and Family Medical Center due to pipe or other penetrations not sealed against the passage of fire and smoke to comply with 8.3.5.1.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 53451 Based on observation and staff interview, fire alarm system components are not installed in accordance with Code requirements. Failure to install components in accordance with requirements can result in failure of the system to operate as intended in the event of an emergency. Findings include: On 07/21/2026 at 10:30 AM, while in the company of D and MM, it was observed that there is not a fire alarm pull station within 60 inches of the horizontal exit to the medical office building to comply with NFPA 72-2010, 17.14.6.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 53451 Based upon observation and document review, the fire alarm system is not being maintained in accordance with Code requirements. Failure to properly maintain the fire alarm system can result in failure of the system to operate as intended to warn occupants of a fire/smoke event. Findings include: On 7/21/2026 at 1:30 PM, while in the company of the MM and MC, it was observed that a failure was identified for a fire alarm strobe in the FMC corridor, on the annual inspection and testing of the fire alarm system dated 3/20/2026, and documentation for repair was not available for review, as required by NFPA 72-2010 14.2.1.2.2.”

“NUMBER OF BEDS AND LENGTH OF STAY CFR(s): §485.620 Condition of Participation: Number of Beds and Length of Stay This Condition is not met as evidenced by: 39025 Based on observation, document review, and interview, it was determined that the CAH (Critical Access Hospital) failed to ensure adherence to the Federal Regulations for length of stay. As a result, condition of participation 42 CFR 485.620, Number of Beds and Length of Stay was not met. Findings include: 1. The CAH failed to ensure compliance with Federal Regulations for length of stay. See deficiency at C-0904.”

“LENGTH OF STAY CFR(s): The CAH provides acute inpatient care for a period that does not exceed, on an annual average basis, 96 hours per patient. This Standard is not met as evidenced by: 39025 Based on observation, document review, and interview, it was determined the CAH (Critical Access Hospital), failed to ensure compliance to Federal Regulations for length of stay. The Findings Include: 1. On 07/15/26 at approximately 10:00 AM during the observational tour, five patients were observed to occupy five individual patient rooms on the medical surgical wing of the CAH. When asked for the patient census, it was explained to this surveyor, they had no in-patients at the time and these individuals were private pay and signed a contract to participate in the Hospital’s nursing care program. 2. The “Nursing Care Resident Acknowledgement Form” dated 02/11/26 was reviewed for each of the five individuals. It stated, “Nursing Care services are provided for the temporary relief of the primary care giver’s responsibilities and are not covered by Medicare, Medicaid or commercial insurance plans. (Name of Hospital) (herein referred to as Hospital) respects the need for nursing care and provides these services on a private pay basis ... If the resident’s stay spans a date when a new rate becomes effective, a new acknowledgement form does not need to be signed. Case Management will send a letter notification of the rate change. Beginning 03/01/2026, advance payment of Nursing Care Room & Board charges will be collected based on the following schedule. If admitted between the 1st and the 19th of the month, payment for the remainder of the current month will be due upon admission. If admitted between the 20th and the end of the month, payment for the remainder of the current monthly, plus the full upcoming month, will be due upon admission. For continuous stays that span contiguous months, the Room & Board charges will be due in full by the 25th of the month for the upcoming month ...” 3. An interview was conducted on 07/15/26 at 11:00 AM with Chief Nursing Executive (E#2). E#2 stated, “We currently do not have any inpatients. The five individuals in the patient rooms on the medical surgical floor participate in our nursing care program and are private pay. They live here. They sign a contract and this is to provide care instead of going to a long-term care facility. They are listed in our electronic record system under acute nursing care. If they need a diagnostic test, we move them to out-patient status, discharge them, then they sign another contract.” 4. An interview was conducted 07/17/26 at 9:00 AM with Chief Financial Officer (E#6). E#6 stated, “These people are in swing bed status. They do not qualify for certified coverage through Medicare, so they are private pay. It’s different accommodation codes in our system, for rate and billing purposes. We report those days as swing-bed on our statistics. Those statistics are what our consulting firm uses for their cost report.” 5. An interview was conducted on 07/17/26 at 9:15 AM with Business Office Manager (E#7). E#7 stated, “These people have ANC (acute nursing care) listed in the system and there is no insurance on the claim, but they are swing-bed status.””

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 53451 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on 7/21/2026, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 39025 Based on observation, document review, and staff interview it was determined the critical access hospital (CAH) failed to ensure safe dietary practices were followed per policy. Findings include: 1. On 07/16/26 at approximately 10:00 AM, a tour of the dietary department was conducted with the dietary manager (E#4). During the tour, the following food items were observed expired. 1) Four (4) bags of basic muffin mix, expired 02/26/25. The following food items had no expiration date. In the refrigerated storage area: 1) Six (6) 5 lb (pound) bags of parmesan cheese. In the dry storage area: 1) Five (5) 5 lb bags of curly egg noodles. 2) Seven (7) 16 oz (ounce) bottles of strawberry desert sauce. 3) One (1) 16 oz bottle of chocolate desert sauce. 4) One (1) 1 gallon container of pepperinci peppers. 5) Three (3) 1 gallon containers of relish. 6) Three (3) 1 gallon containers of pickles. 7) Six (6) 7 lb bottles of ketchup. 8) Four (4) 6 lb bottles of mustard. 9) Six (6) 1 gallon containers of mayonnaise. 10) Thirteen (13) 1 gallon containers of salad dressing. 11) Nine (9) 6 oz jars of marshmallow fluff. 12) Four (4) large plastic see through bins of bread crumbs, cocoa powder, white rice, and graham cracker crumbs. 2. A policy titled, “DATING AND LABELING REFRIGERATED READY TO EAT POTENTIALLY PERISHABLE FOODS” dated 11/10/21 was reviewed. It stated, “POLICY: To ensure refrigerated, ready-to-eat, potentially hazardous food is dated and disposed of within food code requirements ... PROCEDURE: 2. ... If a food product does not have an expiration date, staff shall identify the distributor or manufacturer for the expiration date.” 3. On 07/16/26 at 11:00 AM, an interview with E#4 was conducted. E#4 observed and confirmed the 4 bags of basic muffin mix were expired, and there were no expirations dates on the additional items listed above.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49741 Based on observation, document review, and staff interview it was determined the CAH (Critical Access Hospital) failed to ensure a clean and sanitary environment was maintained to prevent the transmission of infection. Findings include: 1. On 07/16/26 at 9:50 AM, Infection Control Preventionist RN (Registered Nurse) (E#3) in the preoperative area started a Peripheral Intravenous Line on Pt#20. E#3 removed gloves and did not perform hand hygiene. E#3 entered information into the electronic chart via WOW (workstation on wheels), no hand hygiene was performed. E#3 then donned new gloves and instilled eye drops to Pt#20. E#3 removed gloves and charted information into the electronic chart via the WOW, no hand hygiene was performed. 2. On 07/16/26 continuous observation from 10:00 AM to 10:20 AM, Registered Nurse (E#5) donned clean gloves and instilled eye drops to Pt#20. E#5 removed gloves and no hand hygiene was performed. E#5 entered information into the electronic chart via the WOW, no hand hygiene was performed. E#5 donned clean gloves and instilled eye drops to Pt#20. E#5 while wearing the same gloves scanned the patients arm band and entered information into the electronic chart via the WOW. E#5 then removed gloves and hand hygiene was not performed. E#5 went into bay 1, in the preoperative area, to assist another patient. No hand hygiene was performed before entering bay 1. E#5 removed the WOW to common area without disinfecting. 3. The policy titled “Hand Hygiene Policy (effective 6/28/21)” was reviewed on 07/16/26. The policy stated, “Remove gloves after caring for a patient. Perform hand hygiene immediately after removing gloves ...” 4. On 07/16/26, at 11:00 AM, an interview was conducted with the Infection Control Preventionist RN (E#3). E#3 stated, “ hand hygiene should be performed after removing dirty gloves. The computer cart should never be touched with “unwashed hands”, if the cart is touched with “unwashed hands” it should be cleaned with antiseptic wipes before returning it to the computer holding area.””

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 49741 Based on record review and interview, it was determined the Facility failed to ensure the Infection Control program retained documents of surveillance activities. Findings: 1. On 07/16/26, Infection Control binder was reviewed which stated, “HAND HYGIENE COMPLIANCE: Staff returned 10 Hand Hygiene Compliance forms for the month of May 2026. There were 48 opportunities noted with 48 in compliance for the month. Our compliance rate remains at 100% for the past 4 months.” Based on these findings, hand hygiene audits were requested, however, the facility was unable to provide. 2. The policy titled “Infection Control Plan (effective 04/15/20)” was reviewed on 07/16/26. The policy stated, “The responsibility and direct accountability for the surveillance, data gathering, aggregation and analysis is assigned to the Infection Control Preventionist. ...” 3. 07/16/26 at 11:55 AM, E#3 stated there are no hand hygiene audits available for review. “I throw them away after I look at them.””