Inspection·August 14, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few help keep him redirected. Will also get resident a soft helmet to wear to help prevent major injury due to his frequent falls. Therapy will also evaluate resident when he returns for proper wheelchair positioning.R'1 MDS dated [DATE] documents R1's reentry dated to the facility was 7/18/2025.On 8/12/2025 at 2:45 PM, V20 (Physical Therapy Assistant/Director of Rehabilitation) stated R1 received services for occupational and speech therapy from 5/30/2025 to 7/3/2025, then was discharged from therapy services on 7/3/2025. V20 stated therapy did not see R1 after his recent hospitalization to evaluate him for proper positioning when he returned from the hospital on 7/18/2025.R1's Fall Note dated 7/23/2025 at 5:08 PM documents Event: (R1) was waiting for supper in the dining room, leaned forward, fell and landed on his right side. Vital signs WNL (Within Normal Limits), no injuries visible from fall. No wounds or skin tears. (R1) is unable to answer what happened. (R1) has no facial grimacing or signs of pain. (R1) was wearing non-skid socks, nothing on the floor to make him fall, safety helmet was in place which is put in (R1's) orders to wear at all times while out of bed. Action/ Intervention: Reinforce education to (R1) not to get up by himself. Reinforce (R1) to ask staff for help. Notification (Family/ Responsible party/ Physician/ Other): Notified POA (Power of Attorney), DON (Director of Nursing), and Administrator.R1's Fall Note dated 8/12/2025 at 1:58 PM documents Event: (R1) was sitting at the nurses desk, leaned forward, fell and landed on his right side. Vital signs WNL (Within Normal Limits), no injuries visible from fall. No wounds or skin tears. (R1) is unable to answer what happened. (R1) has no facial grimacing or signs of pain. (R1) was wearing his shoes, nothing on the floor to make him fall, safety helmet was in place which is put in (R1's) orders to wear at all times while out of bed. Reinforced education to (R1) not to get up by himself. Reinforced (R1) to ask staff for help. Notified POA (Power of Attorney) and Administrator. Action/ Intervention: Educated (R1) on the importance of waiting for staff to assist. Notification (Family/ Responsible party/ Physician/ Other ): POA (Power of Attorney) and Administrator.On 8/13/2025 7:58 AM-8:48 AM during a continuous observation, at 7:58 AM R1 was sitting at the table in the dining room without his soft helmet on. The soft helmet was sitting on the table. At 8:13 AM V4 (Corporate Nurse) helped R1 put the soft helmet on. R1 does not have non-skid socks or shoes on, he is wearing regular socks that do not have non-skid material on them. On 8/13/2025 at 8:36 AM, V16 (CNA/Certified Nurse's Assistant) stated fall interventions for R1 include wedge under R1, soft helmet while out of bed, fidget blanket, and someone watch him while out of bed. V16 stated that is the only interventions she knows of.On 8/13/2025 at 8:44 AM, during a constant observation, V3 (Corporate Administration) placed a gait belt on R1 and stood him up without assistance. When V3 stood R1 up V1 (Administrator) checked under R1 to see what kind of cushions were present. When V3 lifted R1, R1 had on socks that did not have non-skid material on them. R1 had a wedge cushion with a flat wheelchair cushion under the wedge cushion. There was one side of velcro stuck to the wheelchair seat but the other side of the velcro is not on the bottom of the cushion and there was not a non-skid mat present anywhere on R1's wheelchair. V3 confirmed R1 was not wearing non-skid socks or shoes, R1's socks were socks without non-skid material on them. V3 stated R1 should have his soft helmet on at all times when he is out of bed. V12 (Certified Nursing Assistant) and V16 (Certified Nursing Assistant) then took R1 into the shower room.On 8/13/2025 at 8:50 AM, V1 stated he saw a non-skid mat in R1's wheelchair under the wheelchair pad. This surveyor requested that V1 show the non-skid mat to this surveyor that is in R1's wheelchair. V1 took this surveyor into the shower room and left me with V12 and V16. V1 then exited the shower room.On 8/13/2025 at 8:51 AM, V12 and V16 stated R1 has not left their sight since they took R1 to the shower room and R1 had not been stood up since this surveyor witnessed R1 being stood up by V3 at 8:44 AM. With this surveyor present V12 and V16 finished shaving R1 then when they were (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 08/14/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete finished, they pushed R1 to the bar in the shower room and stood him up. V12 and V16 confirmed there was not a non-skid mat anywhere in R1's wheelchair seat and R1 had on socks without non-skid material on them. On 8/14/2025 at 8:42 AM, V2 (Director of Nursing) stated she doesn't know much about R1 because she just took this position as an interim but stated she was previously the corporate MDS coordinator, so she is familiar with R1. V2 stated since R1's most recent hospitalization she has noticed a decline in R1's physical abilities and she has noticed he is leaning more in wheelchair instead of sitting up straight.On 8/14/2025 at 8:48 AM, V18 (MDS/Care Plan Coordinator) stated falls are talked about in morning meeting and then they come up with interventions that will best help prevent more falls. V18 stated the intervention is put into the care plan then they try to verbally pass along the intervention to the staff directly caring for the residents. V18 stated there is a board in the staff lounge that they use to put the fall interventions on, but they have stopped doing that and there was a paper they put the fall interventions on then would attached the paper to the CNA's clipboard at the nurses station but V18 stated they have stopped doing that as well. V18 stated she doesn't know why they do not do that anymore, but she feels like they need to. V18 stated she also has a binder with fall interventions in it, but it isn't up to date anymore and is full of residents that aren't here anymore. V18 stated she doesn't know why therapy didn't evaluate R1 when he returned from the hospital for positioning in his wheelchair as the care plan states. V18 stated there should have been an order put in for it.A facility policy titled Falls and Fall Risks, Managing (revision date March 2018) documents under Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The same policy documents under Resident-Centered Approaches to Managing Falls and Fall Risk 7. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. 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 08/14/2025 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on interview and observation the facility failed to post the daily staffing data in a prominent place that is readily accessible to residents, staff and visitors. This has the potential to affect all 45 residents who reside at this facility.Findings included:On 8/11/25 at 12:00pm, there were no observations of daily staffing data posted anywhere about the facility. On 08/12/2025 at 11:45pm, there were no observations of daily staffing data posted anywhere about the facility.On 8/12/2025 at 11:57am, V2 (Director of Nursing) said the daily staffing posting used to be hung on the wall directly in front of the nurse's station, but it hasn't been up there in a long time. V2 along with the surveyor looked for daily staffing and found it on a clip board behind the nurse's station upside down and out of sight of visitors or surveyors. V2 said she knows daily staffing posting should be posted in a highly visible area of the nursing home and agrees behind nurse station on clip board is not very visible to the public. V2 said the facility must have just gotten out of the habit of putting up the posting.On 8/12/2025 at 12:15pm, V10 (Business Office Manager) said she has not seen the facility post the staffing data in a long time. V10 said the facility has been putting the staffing posting on a clip board behind the nurse's station. V10 said she did not know the posting had to be posted in a prominent place.The facility policy titled Posting Direct Care Daily Staffing Numbers (revised date July 2016) documented the following in part: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Within two hours of the beginning of each shift, the number of Licensed Nurses (Registered Nurses, Licensed Practical Nurses) and the number of unlicensed nursing personnel (certified Nursing Assistants) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.The facility's matrix dated 8/11/2025 documents the facility has 45 residents. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145008 If continuation sheet Page 4 of 4