Health inspection·October 23, 2024

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 protect a resident from verbal abuse. This failure affects one (R1) of three residents reviewed for abuse in the sample of eight. The findings include: The facility face sheet shows R1 was admitted to the facility with diagnoses to include right tibia (lower leg bone) fracture, atrial fibrillation, weakness, and dementia. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and required set-up assistance with her meals on admission. The facility incident report dated 10/11/2024 for R1 shows her to be oriented to person only and was being encouraged to eat her breakfast. V5 (Certified Nursing Assistant/CNA) was overheard by V3 (CNA) and V4 CNA) telling R1 she had to eat her breakfast, or she would not be able to go home. V5 was later observed by V3 and V4 trying to get R1 to eat and then heard her say [you are fu**ing pathetic]. The incident report also shows the incident was reported to V2 (Director of Nursing/DON) and V5 was escorted from the facility. The facility investigation completed by V1 (Administrator) shows R1 was interviewed and R1 shared no concerns with the care she had received and had never been mistreated or had any staff say anything inappropriate to her. V3 and V4 were interviewed and gave a written statement showing they witnessed the incident. On 10/23/2024 at 9:00 AM, R1 was observed sitting alone in the dining room. R1 said she did not have any complaints about the staff not treating her right and did not recall hearing a staff swear at her. On 10/23/2024 at 9:30 AM, V1 (Administrator) said the abuse was substantiated since they had two staff witnesses of the incident and V5 was terminated from the facility for abuse. On 10/23/2024 at 10:00 AM, a call was placed to V5 (CNA) for her statement, but her number had been disconnected and the facility has no other number for her. On 10/23/2024 at 10:15 AM, V3 (CNA) said they were feeding the residents in the dining room and she had overheard V5 say to R1, you need to eat your breakfast or you can't go home and saying loudly enough for people to hear, you are fu**ing pathetic. On 10/23/2024 at 10:23 AM, V4 said she was present the day of this incident and overheard V5 tell R1 she had to eat her breakfast, or she couldn't go home. V4 said V5 kept trying to get R1 to eat (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 2 Event ID: 146177 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 146177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Resthave Home-Whiteside County 408 Maple Avenue Morrison, IL 61270 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)