Health inspection·July 25, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administration Record (MAR) dated 7/1/2025 -7/31/2025 documents Haloperidol 5mg every 8 hours for agitation related to unspecified dementia, severe without behavioral or psychotic or mood disturbances and anxiety, scheduled for 12:00AM, 8:00AM and 4:00PM with start date of 7/22/2025 at 12:00AM. R3's MAR documents R3 received Haldol 5mg routinely on 7/22/2025 at 12AM, 8:00AM, and 4:00PM, on 7/23/2025 12AM, 8:00AM, and 4:00PM, and on 7/24/2025 at 12:00AM, and 8:00AM. On 7/22/2025 at 12:18PM, V3 (LPN) and V4 (LPN) were interviewed together as V4 is in training and was training on 7/21/2025. V3 stated on 7/21/2025 she was training on the floor and received a phone call from the pharmacy in regard to questions about R3's antibiotics. V3 stated as she started looking at R3's medications, she noticed R3 had returned to the facility on 7/18/2025 and orders were not taken care of until she and V4 took care of the orders. V4 stated there were medications given that were to be discontinued like blood pressure medications on return and new medications ordered that were not given due to the orders not being processed. V4 stated she was unsure of what happened but there are several medication errors that occurred.On 7/24/2025 at 1:03PM spoke with V11 (Medical Doctor/MD) in regard to R3's discharge summary medication orders. V11 was asked if he had a discussion with anyone about the Haldol. V11 stated they talked about the hospice type medications including Haldol. V11 was asked why they changed the Haldol from PRN (as per discharge orders) to routine every 8 hours. V11 stated he was unaware of this and was told the Haldol was every 8 hours as needed and only for 14 days and this is what he gave orders for. V11 stated he would talk with V2 and get that changed immediately.On 7/24/2025 at 1:11PM spoke with V2 in regard to the discharge orders and how the orders are a little confusing. V2 was asked to review the Haldol order for R3. V2 stated he was looking at the orders and the order is Haldol 5mg every 8 hours. V2 was asked where the order came from and V2 stated he was discharged from the hospital with all of the hospice medications including Haldol. V2 was asked if he reviewed the discharge orders specifically the Haldol. V2 stated he thinks he talked to V11 about the Haldol and V11 stated they could try it and see if it helps. V2 was informed that V11 reported to this surveyor that he was unaware that the Haldol was routine, and he thought all of the normal hospice orders including Haldol was PRN. V2 stated oh I better call V11 and get something clarified.On 7/24/2025 at 2:22PM, V2 stated he called V11 and the Haldol has been completely discontinued. On 7/25/2025 at 11:37 AM, the behavior tracking for R3 was requested from V1. V1 stated the behaviors would be charted in R3's progress notes. V1 was asked if there was any behavior tracking on R3 prior to the Haldol and V1 stated again the behaviors would be charted in a progress note. V1 was asked if behavior charting with interventions available for R3 and V1 stated no. There was no documentation of behaviors in R3's Progress Notes since his return from the hospital on 7/18/25 and starting the order for Haloperidol on 7/22/25.On 7/23/2025 at 2:15 PM, a facility policy was requested for the use of chemical restraints from V2. V2 stated he would look for one but was not sure he had one. The requested policy was never produced by the end of this survey on 7/25/25. 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 07/25/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to process and transcribe physician orders timely and accurately for 1 of 3 (R3) residents reviewed for medications in a sample of 3. R3's admission Record documents an admission date of 6/30/2023 and includes but not limited to diagnoses of Chronic Eosinophilic Pneumonia, Pneumonitis due to Inhalation of Food and Vomit, Unsteadiness on Feet, Unspecified Dementia, Hypomagnesium, Generalized Epilepsy, Anxiety, and Parkinson's disease. R3's MDS (Minimum Data Set) dated 6/6/2025 documents R3 is rarely understood and is severely impaired. Section GG documents R3 is dependent on staff for transfers and showers and requires substantial/maximum assistance for lower body dressing and putting on and taking off footwear. Section E-Behaviors documents R3 has no hallucinations or delusions, and that R3 has physical behavioral symptoms directed towards others with behaviors of this type 4 to 6 days, but less than daily. R3 has no behaviors exhibited for rejection of care or wandering. R3's care plan documents focus potential for behaviors: resident to resident inappropriate touching, date initiated 5/7/2025. Goal is to decrease risk of behaviors dated 5/7/2025 with target date of 8/14/2025. Interventions/tasks include but not limited to 1:1 activity with be increased, as well as keeping him engaged in meaningful activities, medication review will be completed and referral to be made to geriatric behavioral unit for evaluation dated 5/7/2025, medications as ordered, observe behaviors and try to determine cause.On 7/22/2025 at 11:00AM, V6 (Registered Nurse/RN) stated she was working on 7/18/2025 when R3 returned from the hospital. V6 stated she noticed R3 did not return with any paperwork, so she called the hospital. V6 stated she never received the orders before she left but later realized the orders were laying on the desk. V6 stated she did not process the orders received from the hospital discharge summary prior to leaving work at 6:00PM on 7/18/2025. V6 stated no medications were done on that day or assessments.On 7/22/2025 at 12:18PM, V3 (Licensed Practical Nurse/LPN) and V4 (LPN) were interviewed together as V4 is in training and was training on 7/21/2025. V3 stated on 7/21/2025 she was training on the floor and received a phone call from the pharmacy in regard to questions about R3's antibiotics. V3 stated as she started looking at R3's medications, she noticed R3 had returned to the facility on 7/18/2025 and orders were not taken care of until she and V4 processed the orders from the discharge summary from hospital return on 7/18/2025. V4 stated there were medications given that were to be discontinued on return and new medications ordered that were not given due to the orders not being processed. V4 stated she was unsure of what happened but there are several medication errors that occurred.R3's progress note documents on 7/21/2025 at 2:58PM (type of note is admission Summary) resident returned to facility on July 18th, 2025. Medication changes were made per hospitalist. Orders were not updated in computer by nurse on duty. Pharmacy called today questioning two antibiotics that were pulled from E-Kit. Upon further investigations, orders changed from hospital and were not updated in the system. Per V2 (Director of Nursing/DON), we will update orders now and contact pharmacy. Authored by V4 (LPN).R3's Discharge Information for Receiving Facility sheet with print date of 7/18/2025 at 8:52AM documents to stop medications of Amlodipine 10mg tablet, Aspirin 81mg tablet, Baclofen 10mg tablet, Avodart 0.5mg capsule, Lisinopril 5 mg tablet, and Metoprolol Succinate XL 25mg. R3's Medication Administration Record (MAR) dated 7/1/2025 -7/31/2025 documents R3 continues on Lisinopril 20mg with a discontinued date of 7/21/2025 and Metoprolol 50mg with a discontinued date of 7/21/2025.R3's Discharge Information for Receiving Facility with print date of 7/18/2025 at 8:52AM documents New Medications, Artificial saliva spray with pump ([NAME]-STIR) one spray mouth/throat every 2 hours PRN (as needed), Famotidine 20mg tablet every 12 hours, Haloperidol 5mg every 8 hours (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 07/25/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PRN, Ativan 1 mg every 2 hours PRN, Morphine concentrate 20mg/ml. every 2 hours PRN, Narcan as needed, scopolamine 1 mg 3 days patch every 72 hours as needed, Senna Plus one tablet as needed. R3's MAR dated 7/1/2025 -7/31/2025 documents Artificial saliva spray with pump ([NAME]-STIR) one spray mouth/throat every 2 hours (routinely) with start date of 7/21/2025 at 4:00PM and documents administration schedule of every 2 hours, Famotidine 20mg tablet every 12 hours, with start date of 7/21/2025 at 8:00PM with scheduled times of 8:00AM and 8:00PM, Haloperidol 5mg every 8 hours for agitation related to unspecified dementia, severe without behavioral or psychotic or mood disturbances and anxiety, scheduled for 12:00AM, 8:00AM and 4:00PM with start date of 7/22/2025 at 12:00AM. Ativan 1 mg every 2 hours PRN, Morphine concentrate 20mg/ml. every 2 hours PRN, Narcan as needed, scopolamine 1 mg 3 days patch every 72 hours as needed, Senna Plus one tablet as needed. R3's MAR dated 7/1/2025 - 7/31/2025 documents R3 received Haldol 5mg routinely on 7/22/2025 at 12AM, 8:00AM, and 4:00PM. On 7/23/2025 12AM, 8:00AM, and 4:00PM. On 7/24/2025 at 12:00AM, and 8:00AM. R3 received Artificial saliva spray with pump ([NAME]-STIR) one spray mouth/throat every 2 hours starting at 8:00PM on 7/21/2025 through 8AM on 7/23/2025.On 7/22/2025 at 1:42PM, V2 stated he was aware of the issues with admissions and readmissions. V2 stated he noticed the issues with R3's readmission and the lack of order processes. V2 was asked if there were medication errors and V2 stated Yes I am aware. V2 stated nobody notified him of the lack of completion of the readmission and he found the issue when he was doing his chart checks. V2 stated he notified the physician on 7/21/2025 during the evening time of the issues with the readmission. V2 stated he was aware of the multiple medication errors. V2 stated we are starting an investigation and already starting a QAPI (Quality Assurance Performance Improvement) on admissions and readmissions now. V2 stated MD (Medical Doctor) was notified last night of issues with readmission orders.On 7/23/2025 at 2:30PM V11, (Medical Doctor/MD) stated he was made aware of the issues with the readmission orders for R3 on 7/21/2025. V11 stated he thinks most of the issue came when R3's orders said he was to be Hospice, and the wife was declining Hospice. R3 stated he blames this on the hospital and the hospital should call and report to tell the facility what medications are discontinued, or new medications are started. V11 stated there was no harm to R3 with the medication errors. V11 stated he met with R3's wife and they agree that R3 can continue with the same care at the facility and does not need Hospice involvement. V11 stated he was keeping the hospice medications as PRN (as needed) in case they were needed, such as if R3 has a decline as he is in poor condition.On 7/23/2025 at 12:08PM, R3 was in the dining being fed by V12 (R3's Spouse). R3 would not converse in a conversation or answer any questions. R3 was being assisted with a diet of pureed foods and nectar thickened liquids. V12 stated R3 has not conversed much in a while. V12 stated the hospital wanted him to be on Hospice but she is not ready for that, and he can receive the same treatment at the facility. On 7/23/2025 at 2:07PM observed R3 sitting at nurse's station in wheelchair. R3 would not answer questions but would make eye contact when spoken to.On 7/24/2025 at 1:03PM spoke with V11 in regard to discharge summary medication orders. Informed V11 that the orders to discontinue Metoprolol Succinate XL 25 mg (R3 is on 50mg at facility), Lisinopril 5mg (R3 on 20mg at facility) were discontinued on the hospital discharge summary orders. V11 stated well R3 seems to be doing pretty good without these medications. V11 was informed that R3 remained on the medications and with the dosage that he was on when he went to the hospital upon return. V11 stated ok. V11 was also asked if he had a discussion with anyone about the Haldol. V11 stated they talked about the hospice type medications including Haldol. V11 was asked why they changed the Haldol from PRN (as per discharge orders) to routine every 8 hours. V11 stated he was unaware of this and was told the Haldol was every 8 hours as needed and only for 14 days and this is what he gave orders for. V11 stated he would talk (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 07/25/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with V2 and get that changed immediately. V11 stated he thinks the hospital used an old medication list and that is why the dosages of the blood pressure medications were different. V11 thought all of the PRN medications were going to stay PRN and see how R3 does.On 7/24/2025 at 1:11PM spoke with V2 regarding the discharge orders and how the orders are a little confusing. V2 was asked to review the Haldol order for R3. V2 stated he was looking at the orders and the order is Haldol 5mg every 8 hours. V2 was asked where the order came from. V2 stated he was discharged from the hospital with all the hospice medications including Haldol. V2 was asked if he reviewed the discharge orders specifically the Haldol. V2 stated he thinks he talked to V11 about the Haldol and V11 stated they could try it and see if it helps. V2 was informed that V11 reported to this surveyor that he was unaware that the Haldol was routine, and he thought all of the normal hospice orders including Haldol was PRN. V2 stated, Oh I better call V11 and get something clarified.On 7/24/2025 at 2:22PM, V2 stated he emailed the requested records and V2 stated he called V11, and the Haldol has been completely discontinued. V2 was also informed the Artificial saliva spray with pump ([NAME]-STIR) one spray mouth/throat every 2 hours was routinely scheduled, and the discharge orders were for PRN. V2 stated that was caught yesterday and was discontinued.Policy titled admission Assessment and Follow Up: Role of the Nurse, dated revised September 2012, documents 13. Reconcile the list of medications from the medication history, admitting orders, the previous MAR, and discharge summary from the previous institution, according to established procedures. 14. Contact the Attending Physician to communicate and review findings of the initial assessment and any other pertinent information and obtain admissions orders that are based on findings.Policy titled Reconciliation of Medications on admission dated revised July 2017, documents the purpose of this procedure is to ensure medication safety by accurately accounting for he resident's medications, routes and dosages upon admission or readmission to the facility. Preparation: 1. Gather the information needed to reconcile the medication list. b. Discharge summary from referring facility. e. Most recent medication administration record (MAR) if this is a readmission. General Guidelines, 4. Medication reconciliation help to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team.Policy titled Medication and Treatment Orders for Admission/readmission and New Orders dated January 2017 documents, all new and readmission medications from the hospital shall be reviewed by the primary physician. If in the event the patient is not admitted or readmitted with clear admission orders it will be up to the discretion of the attending physician on what to order or continue to order. Event ID: Facility ID: 145008 If continuation sheet Page 5 of 5