Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Duquoin Nursing & Rehab during CMS and state inspections, most recent first.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restricted their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with moderate cognitive impairment was physically struck on the elbow with a cane and verbally threatened by a cognitively impaired roommate during an altercation. An LPN witnessed the incident after hearing yelling and cursing, and documentation confirmed the abuse occurred despite facility policies intended to prevent such events.
A cognitively impaired resident with a known history of elopement risk and recent exit-seeking behaviors was able to leave the facility unsupervised. An LPN followed the resident outside but lost sight of her while seeking help, resulting in the resident being unsupervised for over two hours until found by police. Staff interviews revealed inconsistent awareness of elopement protocols and the resident's risk status.
A resident with severe cognitive impairment and anxiety was administered increasing doses of Xanax and a one-time dose of Risperidone without adequate behavioral assessment or documentation, following an elopement incident. After receiving these medications, the resident became drowsy and unsteady, was kept in a wheelchair for safety, and ultimately fell while attempting to ambulate, resulting in a hip fracture that required surgery. Staff and physician interviews confirmed concerns about the appropriateness of the medication regimen and its contribution to the resident's fall.
A resident with moderate cognitive impairment was sent to the hospital due to symptoms like vomiting and fruity-smelling breath. The family was not informed of the transfer until several hours later, despite facility policy requiring prompt notification. The LPN admitted to forgetting to contact the family due to multiple incidents that day.
A resident with a history of breast cancer and recent mastectomy did not receive daily wound dressing changes as ordered by a physician. The facility failed to document dressing changes for 13 days due to a breakdown in communication and process, as orders faxed by the clinic were not received. Despite the oversight, the resident did not suffer adverse events.
The facility failed to maintain proper sanitizer levels in the dish machine and prevent potential contamination of bulk stored foods. A scoop was found in food bins with the handle touching the food, and the dish machine showed no sanitizer concentration. The Dietary Manager admitted to not keeping a log of sanitizer levels, contrary to the facility's policy requiring regular checks.
A resident with multiple health conditions did not receive adequate assistance with ADLs, including shaving and denture care, despite having a care plan requiring staff participation. The resident was not shaved regularly and had unclean dentures, and was also woken up at 3 am for a bed bath, which he found disruptive. Staff acknowledged the issues, citing scheduling challenges, and the facility's procedures for personal care were not followed.
A resident with multiple wounds was admitted to the facility without proper wound care orders being initiated. Despite having specific discharge instructions from the hospital, the facility did not document or execute wound care for several days. Staff interviews revealed confusion and lack of communication regarding the orders, with attempts to contact the hospital for clarification proving unsuccessful. The facility's physician noted he should have been contacted to provide necessary orders.
A facility failed to ensure a resident was free from unnecessary medications, specifically psychotropic drugs. The resident was observed to be excessively tired, attributed to Haloperidol, which was prescribed without consistent evidence of Tourette's syndrome. The facility's process for medication review and behavior tracking was inadequate, with incomplete documentation and lack of follow-up on pharmacy recommendations. Staff noted the resident's increased lethargy and need for assistance, highlighting deficiencies in medication management.
A facility failed to properly label and store a resident's lorazepam, a controlled substance, which was brought in by family members. The medication was kept in a plastic cup with inadequate labeling and was not documented in the narcotic log, contrary to facility policy requiring proper packaging and logging of controlled substances.
The facility failed to provide timely assistance with toileting and bathing for several residents, leading to deficiencies in their care. A resident reported issues with staff not responding to call lights promptly, resulting in inadequate hygiene care. Observations noted residents with oily hair, odors, and unkempt appearances, indicating a lack of proper hygiene care. Inconsistencies in documentation and a lack of a specific shower policy contributed to these deficiencies.
A resident with lymphedema and chronic venous hypertension did not receive prescribed wound treatments on multiple occasions, with no documentation explaining the omissions. Staff interviews confirmed lapses in care and documentation, and some staff were unaware of proper procedures.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. One resident with moderate cognitive impairment was struck on the left elbow with a cane by a roommate who has severe cognitive impairment. The incident occurred during a verbal altercation in their shared room, where the aggressor also threatened to kill the other resident. The altercation was witnessed by an LPN who was passing medications nearby and heard yelling and cursing coming from the room. Upon entering, the LPN observed the physical assault and heard the verbal threats. The resident who was struck confirmed the incident and reported that the aggressor becomes upset and acts out when agitated, specifically mentioning concerns about a missing watch. The facility's records, including progress notes and interviews, document that the incident was reported to facility leadership and the appropriate authorities. The facility's abuse prevention policy states that residents have the right to be free from abuse, including abuse by other residents. Despite this policy, the facility did not prevent the physical and verbal abuse that occurred between the two residents, resulting in a failure to ensure a safe environment as required.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired ambulatory resident with a history of dementia, severe cognitive impairment, and previous elopement attempts was not adequately supervised, resulting in the resident exiting the facility unsupervised. The resident's care plan and assessments documented significant elopement risk, including recent behaviors of exit seeking, packing belongings, and expressing intent to leave. Despite these documented risks and recent incidents of exit-seeking behavior, the resident was able to leave the facility early in the morning, triggering a door alarm. A Licensed Practical Nurse (LPN) responded to the alarm and followed the resident outside, attempting to redirect her back to the facility. The resident was agitated, refused redirection, and continued walking through public areas, including crossing a main highway. The LPN continued to follow but lost sight of the resident in a local business parking lot while attempting to seek assistance. Surveillance footage and witness interviews confirmed that the LPN was separated from the resident, who then left the area unsupervised for over two hours until located by police in a nearby garage. Interviews with staff revealed gaps in knowledge regarding elopement risk assessments, inconsistent communication about the resident's behaviors, and uncertainty about staff responsibilities during elopement incidents. Several staff members did not hear the door alarm, and some were unaware of the resident's elopement risk or recent exit-seeking behaviors. The failure to provide continuous supervision and maintain line of sight with the resident, despite clear documentation of elopement risk, directly led to the resident's unsupervised absence from the facility.
Failure to Prevent Unnecessary Psychotropic Medication Use Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from unnecessary psychotropic medications, resulting in a significant adverse event. The resident, who had severe cognitive impairment, anxiety, and a history of dementia without behavioral disturbances, was admitted with a PRN order for Xanax. Over time, the administration of Xanax was increased from as-needed to scheduled dosing, and a one-time dose of Risperidone was also administered. The decision to increase and add these medications was made following an elopement incident, with the physician relying on staff suggestions and family input, despite the lack of documented behavioral tracking or clear psychiatric indications for the medications. The facility's own policy required thorough assessment and documentation of behavioral symptoms before initiating psychotropic medications, which was not followed in this case. The resident received multiple doses of Xanax and was given Risperidone after initial refusal, with the involvement of family and a police officer to convince her to take the medication. Staff observations and interviews indicated that after the administration of these medications, the resident became increasingly drowsy, confused, and unsteady, with staff noting that she was kept in a wheelchair for safety due to her unsteady gait. Despite these changes, documentation in the medical record inaccurately reflected that the resident's gait was at baseline, and there was no evidence of ongoing behavioral tracking or reassessment of the necessity and effects of the psychotropic medications. Ultimately, the resident attempted to ambulate independently, lost her balance, and sustained a fall resulting in a right hip fracture that required surgical intervention. Staff interviews revealed concerns about the appropriateness of the psychotropic medication regimen, particularly the use of benzodiazepines in an elderly, ambulatory resident, and the lack of communication and assessment regarding the resident's changing condition. The physician acknowledged that the medications likely contributed to the fall and that the prescribed dosages were higher than typically recommended for geriatric patients.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party of a change in condition and transport to the emergency room. This deficiency was identified for one of the seven residents reviewed for notification of changes. The resident, who was moderately cognitively impaired, was sent to the hospital due to symptoms including vomiting dark brown emesis and fruity-smelling breath. The resident's family member was not informed of the hospital transfer until several hours later, at 10 PM, despite the transfer occurring around 12:30 PM. The Licensed Practical Nurse (LPN) involved admitted to forgetting to contact the family due to multiple incidents occurring that day. The Director of Nursing confirmed the protocol for notifying the family after contacting the doctor and arranging the ambulance. The facility's policy requires prompt notification of the resident's representative in the event of a change in the resident's condition or status, which was not adhered to in this instance.
Failure to Change Wound Dressing as Ordered
Penalty
Summary
The facility failed to ensure that a resident's wound dressing was changed in accordance with physician's orders. The resident, who was moderately cognitively impaired, had a history of breast cancer and had undergone a mastectomy. The physician's orders, which were faxed to the facility, specified that the dressing on the surgical site should be changed daily. However, the Treatment Administration Record (TAR) showed no documentation of dressing changes for a period of 13 days, and there were no initials indicating that the dressing change was completed on several specific dates. The deficiency was partly due to a breakdown in communication and process within the facility. The Director of Nursing (DON) stated that the Social Services/Transportation staff member was responsible for receiving and forwarding new orders from outpatient appointments to the nursing staff. However, it was noted that this staff member often became overwhelmed and sometimes failed to forward orders. In this case, the orders were reportedly faxed by the clinic but were not received by the facility, leading to a lack of proper wound care for the resident. The Physician's Assistant expressed concern that the dressing was not changed for 13 days, especially given the resident's recent major surgery and history of cellulitis. Although the resident did not suffer any adverse events, the lack of wound care could have led to serious complications. The facility's policy on medication and treatment orders was not followed, contributing to the oversight in the resident's care.
Sanitizer and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper levels of sanitizer in the dish machine and ensure bulk stored foods were free from potential contamination. During an initial tour of the kitchen, a scoop with a handle was found inside bulk food bins containing thickener and flour, with the handle touching the food substance. The Dietary Manager acknowledged the issue and indicated that containers were available for storing the scoops, but they were not used. This oversight could lead to contamination of the food products. Additionally, the sanitizer concentration in the dish machine was found to be inadequate, as no sanitizer was registering when checked with a test strip. The Dietary Manager admitted that there was no log kept for the sanitizer levels, and it was only checked every few days. The last check for proper sanitization of dishes could not be verified. The facility's policy from 2016 requires the dishwashing machine to be checked three times weekly and after the sanitizer is changed, ensuring proper temperature and chemical concentration are maintained. However, these procedures were not followed, potentially affecting the cleanliness and safety of the tableware and equipment used for food preparation and service.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a resident, identified as R157, who was admitted with multiple health conditions including an unspecified open wound, Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Peripheral Vascular Disease, and an acquired absence of the right leg below the knee. The resident's care plan indicated a need for staff assistance with bathing and personal hygiene. However, observations and interviews revealed that the resident was not receiving timely assistance with shaving and denture care. R157 expressed frustration over not being shaved despite repeated requests and was observed with facial hair, which he stated he did not prefer. Additionally, the resident's dentures were found to be unclean, covered with thick greenish-yellow matter, indicating a lack of regular oral hygiene care. The report also highlighted inappropriate scheduling of bed baths, with the resident being woken up at 3 am for a bed bath, which he found disruptive to his sleep. Staff members acknowledged the issue, citing a need to spread out shower schedules across shifts. The facility's own documents outlined procedures for denture care and bathing, which were not adhered to, as evidenced by the resident's unclean dentures and dissatisfaction with the timing of his personal care. Interviews with staff, including the Director of Nursing and the Regional Nurse, confirmed that the expected standards of care, such as regular shaving and nightly denture cleaning, were not met for this resident.
Failure to Initiate Wound Care Orders for Resident
Penalty
Summary
The facility failed to initiate physician's orders for wound care for a resident with multiple wounds, including an unspecified open wound on the left ankle, a surgical incision on the right knee, and an abrasion on the left great toe. The resident was admitted from an out-of-state hospital with specific discharge instructions for wound care, including the use of a wound vac for the left lateral ankle. However, from the time of admission until several days later, no wound care orders were documented or executed for any of the resident's wounds. The Treatment Administration Record indicated that no wound care was provided during this period. Interviews with facility staff revealed that there was confusion and a lack of communication regarding the wound care orders. The Infection Preventionist and a Licensed Practical Nurse both stated that they did not receive any wound care orders upon the resident's admission and attempted to contact the hospital for clarification without success. The local wound care provider was unable to treat the wounds due to the absence of orders. The facility's physician expressed that he should have been contacted to provide orders if none were available at the time of admission.
Failure to Ensure Resident Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically psychotropic medications, as required by regulations. The resident, identified as R26, was observed to be excessively tired and lethargic, which was attributed to the administration of Haloperidol, a medication that requires a specific diagnosis such as Tourette's syndrome. However, the resident did not exhibit behaviors consistent with Tourette's syndrome, and the diagnosis was only added after a pharmacy consultation report requested it. The facility's Director of Nursing acknowledged that the resident's behaviors were not adequately tracked, and the staff was not properly documenting resident behaviors. The resident's care plan included the use of anti-anxiety medications and interventions for insomnia, but there was a lack of consistent documentation and tracking of the resident's behaviors and medication effects. Observations showed that the resident was often asleep during meal times and required assistance to eat, indicating potential overmedication. The facility's process for gradual dose reduction and pharmacy consultation reports was not effectively implemented, as evidenced by the lack of follow-up on the pharmacy's recommendations and the physician's acknowledgment of the resident's lethargy. Interviews with staff revealed that the resident was initially more alert and independent but had become increasingly tired and required more assistance. The hospice nurse also noted that the Haloperidol might need to be reduced due to the resident's lethargy. The behavior tracking for the resident was incomplete, with many dates lacking documentation of behaviors or medication effects, further indicating a deficiency in monitoring and managing the resident's medication regimen effectively.
Improper Storage and Labeling of Controlled Medication
Penalty
Summary
The facility failed to ensure that medications were labeled as prescribed by a physician for a resident reviewed for controlled medication storage. The resident, admitted with diagnoses including anxiety disorder and insomnia, had lorazepam 0.5 mg tablets brought in by family members. These tablets were stored in a white plastic cup with a brown self-adhering bandage and labeled with the resident's name and a number, but not in a proper container with appropriate identifying information. The medication was kept in the narcotic box of the medication room without a documentation log of the medication being counted, as it was not considered the facility's medication. The Director of Nursing (DON) acknowledged that the lorazepam had been locked up in this manner for over a month and that all controlled substances should be counted and logged prior to each shift. The facility's policy requires medications brought in by families to be sent to the pharmacy for proper packaging and storage. The policy also mandates that medications with missing or incorrect labels should be returned to the pharmacy or family. The facility's failure to adhere to these policies resulted in the improper storage and labeling of the resident's lorazepam, which is a controlled substance.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide timely assistance with toileting and bathing for several residents, leading to deficiencies in their care. Resident 1, who is moderately cognitively impaired and dependent on staff for toileting and bathing, reported issues with staff not responding to call lights promptly. Observations noted that Resident 1 had oily hair, smelled of urine, and wore the same clothes over consecutive days, indicating a lack of proper hygiene care. Despite the presence of shower sheets, there were inconsistencies in the documentation, and Resident 1 expressed dissatisfaction with the care received, including being left in soiled conditions for extended periods. Resident 3, also moderately cognitively impaired, required substantial assistance with toileting and bathing. Observations showed that Resident 3 had dirty nails, an unkempt appearance, and a slight odor, suggesting inadequate hygiene care. A family member expressed concerns about Resident 3 not receiving regular showers and being left in soiled incontinence products, which contributed to skin irritation and frequent urinary tract infections. The family member also noted that Resident 3's oral hygiene was neglected, as evidenced by an unused toothbrush. Resident 7, who is dependent on staff for bathing and toileting, reported that showers were less frequent than before and that staff often assumed refusals without asking. Resident 9, severely cognitively impaired, was observed with oily hair, a slight smell of urine, and food-stained clothing, indicating insufficient hygiene care. The facility's documentation and tracking of showers were inconsistent, with some staff members signing off on shower sheets for showers they did not perform. The facility's transition to a new computer charting system and lack of a specific shower policy contributed to the deficiencies in care.
Failure to Provide Wound Treatments as Ordered
Penalty
Summary
The facility failed to provide wound treatments as ordered for a resident with lymphedema and chronic venous hypertension with ulcers. The resident's treatment administration records (TARs) showed multiple instances where wound care was not administered as prescribed, with no documentation explaining the omissions. The resident reported that dressings were not changed as required, sometimes going several days without treatment. Interviews with staff confirmed the lapses in care and documentation. The resident's medical records indicated specific orders for wound care, including the application of betadine solution, gauze, and absorbent pads, to be changed twice daily and as needed. However, the TARs documented numerous days where the treatments were not performed, and no reasons were provided for these omissions. The Director of Nursing (DON) acknowledged that a progress note should be made to explain why treatments were not given, but this was not done. Further interviews revealed that some staff were unaware of the proper documentation procedures. The Licensed Practical Nurse (LPN) responsible for some of the missed treatments admitted to not knowing how to chart in the TARs. Despite these lapses, the resident's wounds showed some improvement over time. The facility's wound care policy required detailed documentation and reporting, which was not adhered to in this case, leading to the identified deficiency.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Du Quoin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairview Rehab & Healthcare | 0.1 mi | — | 0 | 0 |
| Pinckneyville Nursing & Rehab | 9.9 mi | — | 0 | 0 |
| Helia Healthcare Of Benton | 16.1 mi | — | 1 | 0 |
| Integrity Hc Of Herrin | 16.8 mi | — | 2 | 0 |
| Shawnee Senior Living | 16.9 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.