Inspection·August 8, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some get someone to change her. R1 stated she is very unhappy with the shower situation, they do not bathe her often, and if they do it is a sponge bath. R1 stated that sometimes she does not want to get up first thing in the morning for a bath, because her body hurts and it's just painful, when she asks about it later, they tell her she refused when it was her bath time. R1 stated that she has not changed clothes for days. R1 stated that she has talked to administration about not answering call lights, it hasn't gotten any better. R1 stated they will change her sheets and bedding if she asks, and there are one or two aides that will ask her if they can do it. R1 stated she had her call light on earlier and someone came in and turned it off and said they would be back. R1 stated this happens often and they do not come back for a long time. 2. R3's face sheet dated 08/08/2024 documents an admission date of 04/20/2023 with diagnosis in part of Urinary Tract Infection, Alzheimer's disease, dementia, and disorientation. R3's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 11, indicating R1 is moderately cognitively impaired. Section GG documents that R3 requires setup or clean up assistance with oral hygiene, substantial/maximum assistance with toileting, shower/bathing and lower body dressing, and Partial/moderate assistance with personal hygiene. R3's current care plan dated 06/04/2024 documents R3 has an ADL self-care performance deficit with interventions in part: Check nail length and trim and clean on bath day and as necessary. Bathing, dressing, Personal hygiene/oral care, Toilet use: resident requires 1 staff participation. On 08/07/2024 at 12:00pm, the facility Resident Shower List for June, July, and August 2024, where resident showers are logged and tracked documents R3 received a shower on 06/13, refused 07/01 and 07/04, and received a shower on 07/23, 07/25 and 07/30. R1's Electronic Medical Record contains a Skin monitoring: Comprehensive CNA shower Review (Shower Sheets) for the same dates. On 08/07/2024 at 2:49pm, V4 (Corporate Nurse) brought shower sheets for R3 dated 06/17, 06/20, 06/22, 06/24, 06/27, 07/07, 07/18 All of these sheets were signed by V9 (maintenance/CNA) as the CNA. On 08/07/2024, at 8:47am R3 was observed sitting in her chair in a night gown, her hair was not combed. R3's nails appeared to have dirt under them. On 08/07/ 2024 at 4:09pm, R3, who is alert to person and place, stated the staff takes pretty good care of her but she couldn't remember the last time she had a shower, but she sure would like one. V3 stated she felt greasy, and her hair was a mess. R3 was observed in the same nightgown as earlier, dirty nails and had a slight odor. V3's hair and face appeared oily. On 08/07/2024 at 4:38pm, V11 (Family member) stated she feels like they go through periods off and on where R3 is not getting a shower. V11 stated she will say something to staff about it and they will say R3 refuses, but it will get better for a period of time. V11 stated then it goes back to the same thing. V11 stated they will come in and R3 just looks dirty, sometimes she will be wearing the same clothes from the last time they saw her. V11 stated that she knows it is not uncommon for someone to be in the same outfit because they don't visit every day, but you can just tell that it has been slept in and it just looks dirty and sometimes has crusty stuff on it. V11 stated sometimes they come in and R3 will have very soiled depends, like they are very heavy and full of urine. V11 stated R3 goes through periods of having skin irritation, bilaterally in her groin and under her left breast. V11 stated she knows that is from poor hygiene because it was not an issue prior to R3's decline in being able to care for herself. V11 stated at times they will shower R3 or give her a sponge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 2 of 5 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 08/08/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bath. V11 stated R3 can be resistive at first and say no I do not really want to, especially in the mornings, but we will tell her we want to hug on you, and you have an odor, she will usually get embarrassed and agree to take one. V11 stated R3 is never mean, she just says no I don't feel like it. V11 stated she has spoken with staff about their approach or re-offering it to R3 at a different time when they say she refuses, and they really do not offer much feedback. V11 stated R3 has been getting more frequent Urinary Tract Infections, something that wasn't common before. V11 stated that she knows that is common in Nursing home populations, but the fact that R3 sits in a soiled depends for too long probably also contributes to that. V11 stated there has been a brand new toothbrush in R3's bathroom for over a year that has not been used, she has questioned if they are brushing her teeth and has been met with the same response that she refuses at times. V11 stated her hands and nails appear very dirty often. On 08/08/2024 at 11:16am, R3 was still in the same night gown as the previous day, hair remains uncombed, face, hair and nails still appear dirty. 3. R7's face sheet dated 08/08/2024 documents an admission date of 03/04/2009 with diagnosis in part of nontraumatic intracerebral hemorrhage and other chronic pain. R7's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 12, indicating R7 is moderately cognitively impaired. Section GG documents that R7 is dependent for toileting, Shower/bathing, upper and lower body dressing and personal hygiene's current care plan dated 08/08/2024 documents R7 has an ADL self-care performance deficit with interventions in part: I am unable to bathe independently with interventions of: I prefer bathing in the mornings, one person to assist me with bathing. On 08/07/2024 at 12:00pm, the facility Resident Shower List for June, July, and August 2024, where resident showers are logged and tracked documents R7 received a shower on 06/27, 07/22, and 07/25. R7's Electronic Medical Record contains a Skin monitoring: Comprehensive CNA shower Review (Shower Sheets) for the same dates. On 08/08/2024 at 8:13am, R7 stated they used to shower and shave him what seemed like all the time. R7 stated he actually decided to start growing out his beard because they were shaving him too much. R7 stated lately it is not as often he gets a shower. He stated he will refuse to be shaved at times, but not shower. R7 stated they hardly even ask him anymore; they just assume he doesn't want it. R7 stated he also asks to go to the bathroom when he has to have a bowel movement and they wait until he has an accident and then they are frustrated with him. R7 stated that he doesn't want to make too much of a fuss about it because they say he is demanding, but it is all humiliating. 4. R9's face sheet dated 08/08/2024 documents an admission date of 01/06/2023 with diagnosis in part of chronic pain. R9's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 06, indicating R9 is severely cognitively impaired. Section GG documents that R9 requires setup or clean up assistance with oral hygiene, supervision or touching assistance with toileting, substantial/maximum assistance shower/bathing and Partial/moderate assistance with personal hygiene. R9's current care plan dated 06/04/2024 documents R9 has an ADL self-care performance deficit with interventions in part: assistance with dressing/undressing, assist with oral/dental hygiene, perform self-care if able. On 08/07/2024 at 12:00pm, the facility Resident Shower List for June, July, and August 2024, where resident showers are logged and tracked documents R9 received a shower on 06/29 and 07/21. R9's Electronic Medical Record contains a Skin monitoring: Comprehensive CNA shower Review (Shower Sheets) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 3 of 5 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 08/08/2024 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 0677 for 06/30/2024. Level of Harm - Minimal harm or potential for actual harm On 08/07/2024 at 2:49pm, V4 (Corporate Nurse) brought shower sheets for R9 dated 06/03, 06/08, 06/10, 06/15, 06/17, 06/21, 06/26, 07/03, 07/10, 07/13, 07/17, 07/20, 07/24, 07/27, 07/29. All of the shower sheets with the exception on 07/20 were signed by V2 (DON) as the charge nurse. The shower sheet from 07/20 was signed by V9 as the CNA. Residents Affected - Some On 08/08/2024 at 1:39pm, R9 had a slight smell of urine, she had long chin hair, her hair appeared oily, and her scalp was visibly flaky, and her shirt had what appeared to be dried food on it. On 08/07/2024 at 10:53am, V6 (CNA) stated that everyone should get showers two times a week. V6 stated the shower schedule is posted in the bathroom, in a cabinet and at the nurses station. V6 stated if someone refuses, they are to write it on the CNA shower sheet. She stated R1 often takes a bed bath and refuses to get out of bed. V6 stated that sometimes it is difficult to get showers completed on their scheduled day depending on staffing, but for the most part they are done. V6 stated shower sheets are to be done every day that someone is scheduled a shower, whether they take one or not, they are then supposed to put the shower sheets on the clipboard at the desk to be reviewed and scanned in to the chart. On 08/07/2024 at 10:55am, V7 (CNA) stated everyone is to be showered twice a week. V7 stated the shower schedule is on the clipboard at the nurse's station and that is where they are to put the CNA shower sheets when they are completed. V7 stated they are expected to complete one every day that someone is scheduled to have a shower, even if they refuse a shower. V7 stated if they refuse, they are supposed to report it to the nurse and the nurse is supposed to come down and speak with resident. V7 stated they try as hard as they can to get them done as they are supposed to. On 08/07/2024 at 1:30pm, V5 (Licensed Practical Nurse), stated they sign off on the shower sheets that the CNA's place in the folder at the nurse's station and then they go back in there to be scanned in. V5 stated nurses look over them, but to her knowledge they do not ensure that the showers for that day were completed. V5 stated that the CNA has to offer the shower twice and then the nurse must try. V5 stated they do not have to make note of it, it is the CNA's job to document the refusal. On 08/07/2024 at 1:33pm, V3 (Infection Control Nurse) stated that she is responsible for maintaining the shower log. V3 stated she collects the CNA shower sheets from the nurse's station and logs them. V3 stated they started putting them in a file folder about a week and a half ago which was V4's idea because they were, Getting lost. V4 stated they have been having in-services on showers lately, and shower education books were just done and placed in the shower rooms. V4 stated that she logs the shower sheets and then the front desk scans them in. On 8/7/24 at 2:36pm, V2 (Director of Nurse's/DON), stated the transition to the new computer charting system has been difficult. V2 stated their expectation is that they are doing both right now, filing out the shower sheets and charting in the computer. V2 stated recently they were requiring CNA's to have shower sheets signed off on by the charge nurse before they put them in the folder. V2 stated the CNA assigned to the resident's hall is expected to complete the showers, but this has been an issue and they were talking about assigning a specific CNA to a specific resident that way they knew exactly who's responsibility it was. V2 stated if someone refuses, the nurse must go down and also speak with the resident about it. V2 stated she and V3 have been checking in to make sure showers are getting done, and verbal warnings have been given to people not completing them. V2 stated that the shower schedule and the shower education books were placed in the shower rooms after an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 4 of 5 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 08/08/2024 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 0677 in-service, but some have been removed due to remodeling the bathrooms. Level of Harm - Minimal harm or potential for actual harm On 08/07/2024 at 2:49pm, V4 (Corporate Nurse) stated there was no book on shower education or a specific policy on showering, the only policy they had on bathing was their general ADL policy. V4 brought a stack of shower sheets in and stated she had retrieved them from various places. Residents Affected - Some On 08/08/2024 at 10:10am, V3 (Infection Prevention Nurse) stated there was no system for showers or tracking them before she and V2 took over and started putting a system in place. V3 stated that everyone knows that the shower sheets are to go on the clipboard, in the folder at the nurse's station. V4 stated that yesterday they started assigning a resident shower to a specific CNA so they could figure out where the problem still remains. On 08/08/2024 at 10:47am, V9 (Maintenance/CNA) stated he does not work the floor often, maybe a couple times a month here and there. V9 stated he was asked to sign a stack of shower sheets yesterday and that he did not give those showers. On 08/08/2024 at 11:25am, V2 (DON) stated that she started her position as DON on June 12, 2024, prior to that the facility had not had a DON for a while. V2 stated she and V9 were asked to sign shower sheets yesterday that they did not give nor were they present for those showers. Facility policy titled, Activities of Daily Living (ADLs), Supporting with a revision date of March 2018, documents residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, Grooming and personal and oral hygiene. This document further states if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 5 of 5