Inspection·May 21, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lower leg to no higher than 2 inches. Left lower leg: Cleanse with normal saline, paint open/weeping areas with betadine solution. Cover with gauze followed by ABD's. Wrap with rolled gauze and secure with coban starting at the base of toes up lower leg to no higher than 2 inches below the bend of the knee. R1's TARs dated April 2024 documents for the right lower leg, 4/13/24, 4/14/24, 4/15/24, 4/17/24, 4/18/24, 4/24/24, 4/27/24 all have N (no) documented in the 8:00 AM treatment time. The left lower leg also has N documented on the 4/13/24, 4/14/24, 4/15/24, 4/17/24, 4/18/24, 4/24/24, 4/27/24 times. There was no documention found in R1's record stating the reason the treatments were not administered. R1's Physician's Order Summary Report documents an order dated 4/19/24 for the right lower leg: Cleanse with normal saline, apply calcium alginate to open ulcer and cover with ABD pad. Paint remander of open/weeping area with betadine solution. Cover with gauze followed by ABDs. Wrap with rolled gauze and secure with coban starting at the base of the toes up lower leg to no higher than 2 inches below the bend of the knee. Change two times daily and prn. R1's TAR dated April 2024 documents N on 4/24/24 and 4/27/24. There was no documention found in R1's record stating the reason the treatments were not administered. R1's Physician Order Report documents an order dated 5/1/24 for the left lower leg: Cleanse with normal saline, paint open/weeping areas with betadine solution. Cover with gauze followed by ABDs. Wrap with rolled gauze and secure with coban, starting at the base of the toes up lower leg to no higher to 2 inches below the bend of the knee. Change two times daily and prn. There was no treatment noted on R1's May 2024 TARs for the left lower leg. R1's Physician's Order Summary Report documents an order dated 5/1/24 for the right lower extremity: Cleanse with normal saline, apply calcium alginate to open ulcer and cover with ABD pad. Paint remainder of open/weeping area with betadine solution. Cover with gauze followed by ABDs. Wrap with rolled gauze and secure with coban starting at the base of the toes up lower leg to no higher than 2 inches below the bend of the knee. Change two times daily and prn. R1's May 2024 TAR has no documentation that the treatment was done on the following days: 5/1/24 at 1600 (4:00 pm), 5/2/24 at 1600, 5/3/24, 5/4/24, 5/6/24, 5/7/24, 5/8/24, 5/9/24 at 1600, 5/10/24, 5/11/24, and 5/12/24. On 5/16/24 at 1:30 PM, R1 stated staff do not change his dressing like they are supposed to. R1 said he does good to get it changed once a day and sometimes it doesn't get changed at all. R1 said he went 6 days last week and it did not get changed. On 5/16/24 at 2:00 PM, V2 (Director of Nurses/DON) stated that a N on the TARs means the treatment was not given and a progress note should be done to explain why it was not done. On 5/17/24 at 11:30 AM, V2 said she was made aware of problems with dressing changes not being done on R1 and did an inservice to staff. V2 said she is working on fixing the problem. On 5/16/24 at 11:45 AM, V3 (Licensed Practical Nurse/LPN/Infection Preventionist) said there were a couple of days she did not do R1's dressing change. V3 said the lymphedema clinic called on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 2 of 4 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 145008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Duquoin Nursing & Rehab 514 East Jackson St Du Quoin, IL 62832 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 15th of May and said the dressing changes were not being done. V3 said she did not know she could chart in the TARS (Treatment Administration Record) and has never signed a dressing change off on them. V3 also said that R1's wounds on both legs have improved alot since his admission. R1's Wound Healing Progress Report note on admission date of 3/29/24 documents R1's left leg wound measured 20.00 x 61.20 and right calf measured 20.00 x 57.50 x 0.30. On 5/16/24 measurements of the left leg were noted to be 18.70 x 40.20 and the right calf measured 10.00 x 20.00 x 0.20. The Facility Wound Care Policy documents under the heading Documentation: The following should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 3 of 4 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 145008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Duquoin Nursing & Rehab 514 East Jackson St Du Quoin, IL 62832 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 0684 The signature and title of the person recording the data. Level of Harm - Minimal harm or potential for actual harm Under Reporting, the Wound Care policy documents: 1. Residents Affected - Few Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice. Prior to the survey date, the facility implemented the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 5/13/24. Staff in attendance included the Medical Director, Administrator, Director of Nursing, Infection Preventionist, Regional Clinical Nurse and MDS Specialist. An action plan was developed to include goals of all medication/treatment administration records to be completed in their entirety in real time and all treatment changes will be completed according to the current physician order. The action documented included education of all nursing staff and monitoring to be completed x (times) 4 weeks. 2. Nursing In-Service/Education was provided to all nursing staff documenting the importance of ensuring all dressing changes are completed as ordered; if at any time for any reason an appointment for wound clinic is missed, nurses are required to perform treatments as ordered, the importance of completing the MAR/TAR documentation daily, and importance of completing weekly skin assessments. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: DON or Designee to monitor dressing changes daily for 1 week then 3 times weekly for 2 weeks, then weekly for 2 weeks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 4 of 4