Health inspection·August 22, 2024

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement current behavior interventions for a resident with inappropriate sexual behaviors and failed to re-assess and implement progressive individualized interventions for increased occurrences of unwanted sexual behaviors for 1 (R1) of 3 residents reviewed for behavioral health in the sample of 5. Findings include: R1's face sheet documented an admission date of 4/12/24 with diagnoses including metabolic encephalopathy, epilepsy, cerebral infarction. R1's 7/14/24 Minimum Data Set, dated [DATE] documented no Brief Interview for Mental Status (BIMS) score due to R1 being rarely/ never understood. A handwritten document was provided by the V1 (Administrator) that documents interviews from R9 and R8 regarding an incident with R1. At the top of the document, it reads Interviews on 5/21/24. R9's interview: He (R1) followed (R8) to our room. (R8) went into the bathroom. He (R1) pulled the curtain and sat down on (R8's) rollator. He (R1) then got up and left the room. Later he (R1) came back in the room. He (R1) sat down on (R8's) bed. He (R1) pulled the curtain both times. We (R9 and R8) both told him to go. R8's interview: He (R1) followed me down here (room). I told him (R1) I had a roommate. He (R1) didn't stop. I went into the bathroom, and he (R1) sat down on my rollator. He (R1) came back to our room again after leaving the first time. He (R1) pulled the curtain and sat on the edge of my bed. He (R1) leaned over and kissed me on the lips two times. I motioned for him to leave. R9 yelled for staff. Staff led him away. R1's care plan documented a focus area initiated on 5/24/24 . I currently have an alteration in my behavior status (related to) agitation, wandering, inappropriate sexual behaviors . and listed the following interventions/ tasks: 5/24/24 my behaviors will be monitored every shift and documented, 5/24/24 Intervene as necessary to protect (R1's) rights and safety of others. Approach/ speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, 5/24/24 Minimize potential for the disruptive behaviors by offering tasks which divert attention such as encourage activity participation and monitored outdoor time, 5/24/24 Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes, 5/24/24 Praise any indication of (R1's) progress/ improvement in behavior, 5/30/24 Behavior - Inappropriate Sexual Behavior, 7/30/24 15-minute checks. A facility incident report regarding R1 and R7 dated 8/12/24 documented alleged abuse between R1 and R7 on 8/4/24. Both residents are marked as not interviewable. Under Detailed incident summary . the following is documented: This administrator was educated about an alleged incident between (R1) (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 146124 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 146124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE White County Rehab and Nursing 615 West Webb Street Carmi, IL 62821 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)