Health inspection·January 8, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 6. Findings Include: R2's admission Record documents an initial admission date of 11/21/2022. R2's admission Record documented the following diagnoses of down syndrome, unspecified, type 2 diabetes mellitus without complications. R2's Minimum Data Set (MDS) annual assessment dated [DATE], documented a Brief Interview for Mental Status Score of 15, indicating R2 is cognitively intact. R1's admission Record documents an initial admission date of 5/1/2022. R1's admission Record documented the following diagnoses of major depressive disorders, generalized anxiety disorder and delusional disorders. R1's Minimum Data Set (MDS) quarterly assessment dated [DATE], documented a Brief Interview for Mental Status Score of 15, indicating R1 is cognitively intact. R1's Facility Progress Notes dated 12/20/2024 at 10:11 AM by V9 (Licensed Practical Nurse/LPN), documented when other patient (R2) ask patient (R1) to stop yelling, he says he'll beat their f***ing ass to come outside. R1's Facility Progress Note dated 12/20/2024 at 5:17 PM by V9 (LPN) documented, R1 agreed to go to the local hospital to be assessed to see if acute infection causing change in his behavior or seek mental health help. Local ambulance called and transported R1 to local hospital. On 1/7/2025 at 10:15 AM, V9 (Licensed Practical Nurse/LPN) stated that R1 and R2 did have an argument in the dining room on 12/20/24. V9 stated that R1 was hollering at R2 and said, shut the f**k up. V9 stated when R2 asked R1 to be quiet, R1 said he will beat his f***ing ass to come outside. V9 stated, she did contact V2 (Director of Nursing/DON) to notify her of R1's behavior. V9 stated that V2 told her to separate R1 and R2, contact R1's physician and/or send R1 to the local emergency room for evaluation. V9 stated that she did leave a message for R1's physician (V10) and when V10's office returned her call related to R1 and said R1 could go to the hospital for mental health or do an emergency discharge due to R1 threatening people and destroying property. V9 stated, R1 did agree to go to the local hospital for evaluation. (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 4 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 01/08/2025 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)