Inspection·July 9, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from physical and verbal abuse for 1 (R1) of 3 residents reviewed for abuse in the sample of 7. Findings include: R1's admission Record documents an initial admission date of 6/25/2025. This same document listed the following diagnoses of cellulitis of right and left lower limb, chronic kidney disease and venous insufficiency. R1's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status Score of 11, indicating R1 had moderate cognitively impairment. R2's admission Record documents an initial admission date of 6/26/2025. This same document listed the following diagnoses of dementia in other diseases classified elsewhere, mild, with other behavioral disturbances, insomnia, and type 2 diabetes mellitus without complications. R2's Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status Score of 0, indicating R2 had severe cognitively impairment. On 7/5/2025 at 12:48 PM V3 (Licensed Practical Nurse/LPN) stated, she had been in the process of passing medications around 8:00 am to residents when she heard yelling and cussing coming from R1 and R2's shared room. V3 stated, when she went into R1 and R2's shared room, she witnessed R2 hit R1 on her left elbow with his cane. V3 stated, R2 continued to yell at R1 I will kill you. V3 stated, R1 told her that R2 does get like this when he is angry or upset. V3 stated, V4 (Regional Director of Operations) did direct her to separate R1 and R2 from each other, call the police and Illinois Department of Health (IDPH) to report incident. On 7/5/2025 at 1:16 PM R1 stated, R2 became upset about his father's watch missing this morning. R1 stated, R2 does worry about his watch all the time. R1 stated, R2 did push her with the end of the cane in her left elbow. On 7/5/2025 at 3:02 PM V2 (Director of Nursing/DON) stated, V3 (LPN) notified him of an argument between R1 and R2 that occurred 8:00 AM. V2 stated, V3 notified him that R2 hit R1 with his cane to her left arm but, there were no marks or injuries to the area. V2 stated, V3 told him that R2 said to R1 that he was going to shoot her and put her in the ground. V2 stated, V1 (Interim Administrator) and V4 (Regional Operations Director) were notified, along with the local police department. (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 2 Event ID: 145008 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 07/09/2025 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)