Duquoin Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent future falls for 1 of 4 (R1) residents reviewed for falls in a sample of 30. R1's admission Record documents an initial admission date of 6/30/2023 with diagnoses including in part dementia, muscle weakness, other abnormalities of gait and mobility, unsteadiness on feet, altered mental status, and lack of coordination. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score is unable to be performed because R1 is rarely/never understood. The same MDS for R1 documents the number of falls since admission as two or more, and R1 is dependent for sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Dependent is defined in the same MDS as Dependent-Helper does all the effort. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from unnecessary psychotropic medications for 1 of 3 residents (R3) reviewed for medications in a sample of 3.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision of a cognitively impaired ambulatory resident in 1 of 3 residents (R4) reviewed for elopement risk in the sample of 3 residents. The failure resulted in R4 exiting the facility at approximately 6:30 AM on 5/6/25 and was followed by V3 (Licensed Practical Nurse) to a local business. While in the parking lot of the business, R4 left V3's line of sight which resulted in R4 going unsupervised from approximately 6:50 AM until 9:10 AM when R4 was located in the garage of a local residence by the police. The Immediate Jeopardy began on 5/6/25 at approximately 6:50 am when V3 lost sight of R4 after R4 had exited the facility. R4 was not located until 9:10 am when R4 was found in a garage by the police. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from unnecessary psychotropic medications for 1 of 3 residents (R4) reviewed for medications in a sample of 3. This failure resulted in R4 sustaining a fall due to a loss of balance, resulting in a hip fracture requiring surgical intervention.

Inspectors wroteBased on record review and interview the facility failed to notify a residents responsible party of a change in condition and transport to the emergency room for 1 of 7 residents (R2) reviewed for notification of changes in the sample of 10.

Inspectors wroteBased on interview and record review, the facility to ensure that a resident's wound dressing was changed in accordance with physician's orders for 1 of 3 residents (R3) reviewed for wounds in the sample of 10. This past noncompliance occurred from 2/21/25 to 3/06/25.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper levels of sanitizer were maintained inside the dish machine and bulk stored foods were kept free from potential contamination. This has the potential to affect all 53 residents residing in the facility. The Findings Include: During the initial tour of the kitchen on 8/27/24 at 8:00 AM a scoop with handle was found in the bulk food bins containing thickener and flour. At this time V13 (Dietary Manager) stated that there are containers right next to these bins that are supposed to be for the scoops. V13 removed the scoops at this time and was going to educate the staff on the proper procedure of not leaving the scoops in the food with the handle touching the food substance. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to provide assistance with ADL's (Activities of Daily Living) to 1 of 3 residents (R157) reviewed for ADL care in the sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to initiate physician's orders for wound care for 1 of 5 residents (R157) reviewed for skin conditions in the sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 1 residents (R26) reviewed for unnecessary medications in the sample of 26. The Findings Include: R26's face sheet documents an admission date of 6/12/2024. The diagnosis on this face sheet includes the following: senile degeneration of brain as of 6/13/24, anxiety disorder as of 6/13/24, Diabetes Mellitus as of 6/13/24, and Tourette's disorder as of 8/27/2024. R26's physician order summary report as of 8/30/24 documents the following medications: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were labeled as physician prescribed for 1 (R53) of 1 residents reviewed for controlled medication storage in the sample of 26. Findings Include: R53's Face Sheet documented an admission date to the facility as 7/18/2024 with diagnosis including anxiety disorder, unspecified, insomnia, unspecified, malignant neoplasm of unspecified site of left female breast. On 8/27/24 at 2:00 PM, observation of the locked medication storage room with V2 (Director of Nursing/DON) observed a white plastic cup containing white pills inside it that had been wrapped around the top portion of the cup with brown self-adhering bandage. The plastic cup had the number 423 written in a black sharpie marker with R53's name on the cup, locked in the narcotic box of the medication room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents are receiving timely assistance with toileting and bathing for 4 of 6 residents (R1, R3, R7, R9) reviewed for Activities of Daily Living (ADL) assistance in the sample of 6. 1. R1's face sheet dated 08/08/2024 documents an admission date of 03/04/2024 with diagnosis in part of displaced fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, Encounter for other orthopedic aftercare, fracture of right shoulder girdle, subsequent encounter for fracture with routine healing'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 R1 is dependent for toileting, Shower/bathing and personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide wound treatments as ordered for 1 (R1) of 3 residents reviewed for wound treatment in a sample of 3. This past non-compliance occurred between 4/3/24 and 5/12/24.

Inspectors wroteBased on interview and record review, the facility failed to provide showers/baths to dependent residents for 5 of 5 residents (R5, R7, R12, R13 and R14) reviewed for showers in a sample of 14.

Inspectors wroteBased on interview, observation and record review, the facility failed to identify a harness device as a physical restraint and care plan for this device for 1 of 1 resident (R57) reviewed for physical restraints in the sample of 30. Findings Include: R57's Face Sheet printed 07/23/23 documents an admission date to the facility as 09/12/22. R57's face sheet documents current diagnoses in part as Unspecified Atrial Fibrillation, Anxiety disorder due to known physiological condition, abscess of salivary gland, iron deficiency anemia, muscle weakness, sarcoidosis of other sites, hypokalemia, other constipation, unsteadiness on feet, pain unspecified, mixed hyperlipidemia. R57's Minimum Data Set (MDS), dated [DATE] documents a Brief Interview for Mental Status score of 10, indicating moderate impairment. [...]