Health 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. Page 1 of 2 145008 145008 07/09/2025 Duquoin Nursing & Rehab 514 East Jackson St Du Quoin, IL 62832

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Progress Note dated 7/5/2025 at 8:50 AM by V3 (LPN) documented I heard the two residents arguing, walked into room and seen the other resident hit her with the end of his cane. He was also saying I will kill you and put you underground R1's Progress Note dated 7/5/2025 at 9:28 AM by V3 (LPN) documented she was instructed by V2 (DON) to report to Illinois Department of Public Health, spoke with them via phone and made report, they will mail findings and call with any further questions. The Facility's Initial Reportable Event dated 7/5/2025 documented an investigation had been started into the physical and verbal altercation between R1 and R2 that occurred on 7/5/25. The Facility's Abuse Prevention Program Policy (revised December 2016) documented under Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. This same document documented under Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual 145008 Page 2 of 2