Inspection Reports for
Resthave Home of Whiteside
408 Maple Ave, Morrison, IL, 61270
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 29, 2026
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to feeding tube care and antibiotic use in the nursing home.
Findings
The facility failed to ensure accurate measurement and administration of tube feeding for one resident and failed to ensure residents were free from unnecessary antibiotic use. Additionally, the facility did not properly implement and monitor its Antibiotic Stewardship Program.
Deficiencies (3)
F 0693: The facility failed to ensure tube feeding ordered by the physician was accurately measured for one resident, resulting in the resident receiving less formula than ordered.
F 0757: The facility failed to ensure residents were free from unnecessary antibiotics for four residents, with antibiotic orders lacking stop dates and associated diagnoses.
F 0881: The facility failed to implement and follow its Antibiotic Stewardship Program by not monitoring residents for inappropriate and unnecessary antibiotic use.
Report Facts
Residents reviewed for tube feeding: 2
Residents reviewed for unnecessary medications: 5
Residents affected by unnecessary antibiotic use: 4
Tube feeding formula ordered per day: 1200
Tube feeding formula shorted: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing/Infection Preventionist | Named in findings related to tube feeding measurement and antibiotic stewardship monitoring |
| V4 | Registered Nurse | Named in finding related to inaccurate tube feeding measurement |
Inspection Report
Deficiencies: 1
Date: Jan 5, 2026
Visit Reason
The inspection was conducted to evaluate the facility's compliance with safety protocols related to resident transfers, specifically focusing on the use of mechanical stand lifts and prevention of falls.
Findings
The facility failed to safely transfer a resident (R1) using a mechanical stand lift without the required two-person assistance, resulting in a fall and injury. Staff did not follow the facility's transfer policy, and improper use of the sling and lift was observed.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. A resident fell during a mechanical stand lift transfer when only one staff member assisted, contrary to policy requiring two staff.
Report Facts
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V8 | Agency Certified Nursing Aide | Involved in the unsafe transfer of resident using mechanical stand lift |
| V5 | Restorative Certified Nursing Aide | Provided information on transfer policy and incident |
| V2 | Director of Nursing | Provided policy and incident assessment details |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 13, 2025
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaints, including two unsubstantiated complaints and one substantiated facility-reported incident regarding resident safety and appropriateness of admission.
Complaint Details
Complaint investigation 2510267/ IL 184250 and 2510240/ IL 184114 were unsubstantiated. Facility Reported Incident of 9/4/25, IL 197386 was substantiated.
Findings
The facility failed to ensure that one admitted resident (R1) was appropriate for admission, resulting in the resident's elopement, fall, and injury. The facility also failed to comply with the National Fire Protection Association's Life Safety Code related to exit door alarms and the use of wander guards, which are not permitted in Illinois assisted living establishments.
Deficiencies (2)
Failure to ensure that one admitted resident was appropriate for admission, resulting in elopement and injury.
Failure to comply with the residential board and care occupancies chapter of the NFPA Life Safety Code, including issues with exit door alarms and use of wander guards.
Report Facts
Residents reviewed: 3
Resident R1 admission date: Jul 11, 2022
Incident date and time: Sep 4, 2025
Check interval: 15
Exit door alarm delay: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Supervisor | Interviewed staff member (E2) who provided information about resident R1's behavior and condition |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse of a resident by a staff member.
Complaint Details
The complaint investigation was substantiated. The abuse involved a staff nurse yelling at and forcibly moving a resident who was cognitively impaired. The nurse was suspended and terminated after the investigation.
Findings
The facility substantiated abuse of one resident by a staff nurse who yelled at and forcibly moved the resident in her wheelchair against the resident's will. The staff nurse was suspended and subsequently terminated following the investigation.
Deficiencies (1)
F 0600: The facility failed to protect a resident from abuse by a staff nurse who yelled at and pulled the resident backwards down the hall in her wheelchair. The abuse was substantiated by the facility investigation.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Date of abuse incident: Aug 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 RN | Registered Nurse | Named in abuse finding for yelling at and pulling resident |
| V2 Director of Nursing | Director of Nursing | Responded to incident, suspended and terminated V3 RN |
Inspection Report
Routine
Deficiencies: 10
Date: Apr 9, 2025
Visit Reason
Routine inspection of Resthave Home-Whiteside County to assess compliance with healthcare regulations and standards across multiple areas including resident dignity, medication management, nutrition, infection control, and immunizations.
Findings
The facility was found deficient in several areas including failure to treat a resident with dignity, improper medication self-administration procedures, inadequate nutritional supplement provision, delayed pharmacist medication review responses, lack of gradual dose reductions for psychotropic medications, medication administration errors, inaccurate pureed diet portions, failure to implement enhanced barrier precautions for infection control, and incomplete pneumococcal vaccination documentation.
Deficiencies (10)
F 0550: The facility failed to ensure a resident was treated in a dignified manner when a CNA was rude and initially refused to assist with incontinence care.
F 0554: The facility failed to assess and obtain an order for a resident to keep medications at bedside and self-administer medications.
F 0692: The facility failed to ensure nutritional supplements were provided to a resident, who was not assisted or encouraged to eat and refused some supplements.
F 0756: The facility failed to ensure monthly medication reviews were acted on timely by physicians for 4 of 5 residents reviewed.
F 0758: The facility failed to implement gradual dose reductions for psychotropic medications and failed to ensure stop dates on as needed psychotropic orders for 5 residents.
F 0759: The facility failed to ensure medications were administered at the prescribed time, resulting in a 22.22% medication error rate.
F 0760: The facility failed to ensure a significant medication error did not occur when insulin was administered after a meal, risking inaccurate blood sugar readings.
F 0803: The facility failed to follow the menu to ensure nutritional adequacy for residents on a pureed diet, serving incorrect portion sizes.
F 0880: The facility failed to ensure a resident was placed on enhanced barrier precautions for infection control, with staff not wearing gowns or gloves during care.
F 0883: The facility failed to ensure residents received the pneumococcal vaccine for 2 of 5 residents reviewed for immunizations.
Report Facts
Medication error rate: 22.22
Residents reviewed: 32
Residents affected by dignity deficiency: 1
Residents affected by medication self-administration deficiency: 1
Residents affected by nutritional supplement deficiency: 1
Residents affected by medication review deficiency: 4
Residents affected by psychotropic medication deficiency: 5
Residents affected by pureed diet deficiency: 6
Residents affected by infection control deficiency: 1
Residents affected by pneumococcal vaccine deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in multiple findings including dignity issue, medication review, psychotropic medication management, medication errors, infection control, and immunizations |
| V6 | Licensed Practical Nurse | Named in medication administration error finding |
| V10 | Pharmacist | Named in medication review and gradual dose reduction findings |
| V4 | Dietary Manager/Dietitian | Named in nutritional supplement and pureed diet findings |
| V14 | Social Service Director | Named in immunization findings |
| V7 | Certified Nursing Assistant | Named in infection control deficiency |
| V8 | Certified Nursing Assistant | Named in infection control deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify a resident's Power of Attorney after a fall and skin tear, and concerns about fall prevention and assessment practices.
Complaint Details
The complaint involved failure to notify the resident's Power of Attorney timely after a fall and skin tear, inadequate assessment following falls, lack of staff awareness of fall history and interventions, and failure to implement fall prevention measures. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to notify the resident's Power of Attorney promptly after a fall, failed to assess a resident with a history of falls properly, and did not implement or communicate appropriate fall interventions. Staff were unaware of the resident's fall history and care plan interventions were incomplete.
Deficiencies (2)
F 0580: The facility failed to immediately notify a resident's Power of Attorney after the resident experienced a fall and a skin tear. Notification was delayed until the morning after the fall.
F 0689: The facility failed to ensure a resident with a history of falls was assessed after a reported fall and failed to implement or communicate appropriate fall interventions. Staff were unaware of the resident's fall history and care plan lacked key interventions.
Report Facts
Residents affected: 1
Fall dates: 4
Wound size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding notification policy and fall assessment responsibilities |
| V3 | Registered Nurse | Recalled working during fall incidents and stated lack of awareness of falls |
| V8 | Certified Nursing Assistant | Reported knowledge gaps about resident fall history and interventions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse involving resident R1 and resident R2.
Complaint Details
The complaint investigation substantiated that resident R1 was witnessed touching resident R2's breasts without consent. Resident R2 was asleep and did not respond. The facility intervened immediately and reported the incident to the Illinois Department of Public Health.
Findings
The facility failed to ensure a resident was free from abuse, as staff witnessed resident R1 inappropriately touching resident R2. The incident was observed and reported by multiple staff members, and no injury was found to resident R2.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical and sexual abuse. Resident R1 was observed touching resident R2 inappropriately despite R2 being unresponsive.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal abuse of a resident by a staff member.
Complaint Details
The complaint was substantiated based on witness statements and facility investigation. The resident did not recall the incident, but two staff members confirmed the verbal abuse. The staff member responsible was terminated.
Findings
The facility substantiated verbal abuse of one resident by a Certified Nursing Assistant who used inappropriate language. The staff member was terminated following the incident.
Deficiencies (1)
F 0600: The facility failed to protect a resident from verbal abuse by a staff member who told the resident she was 'fu**ing pathetic' during meal assistance. The abuse was witnessed by two staff and substantiated by the facility.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Certified Nursing Assistant | Named in verbal abuse finding and terminated for abuse |
| V2 | Director of Nursing | Reported abuse and involved in investigation |
| V1 | Administrator | Completed facility investigation and substantiated abuse |
| V3 | Certified Nursing Assistant | Witnessed verbal abuse incident |
| V4 | Certified Nursing Assistant | Witnessed verbal abuse incident |
| V7 | Registered Nurse | Provided statement on meal refusal and staff conduct |
Inspection Report
Routine
Census: 62
Deficiencies: 3
Date: Mar 21, 2024
Visit Reason
Routine inspection of Resthave Home-Whiteside County to assess compliance with healthcare regulations including resident care, diagnostic services, and food safety.
Findings
The facility failed to notify the dietitian and provide weekly weights for a resident with significant weight loss, failed to provide timely diagnostic services for a resident with symptoms of a blood clot, and failed to cover foods during delivery, change gloves during food service, and maintain a cleaning schedule in the kitchen.
Deficiencies (3)
F 0692: The facility failed to notify the dietitian and provide weekly weights for a resident with significant weight loss. This applied to 1 of 4 residents reviewed for weight loss.
F 0776: The facility failed to provide timely diagnostic services for a resident experiencing symptoms of a blood clot. This applied to 1 of 3 residents reviewed for hospitalizations/diagnostic services.
F 0812: The facility failed to cover foods delivered to residents' rooms, failed to change gloves during food service, and failed to have a cleaning schedule in place. This applied to all residents in the facility.
Report Facts
Residents in facility: 62
Weight loss percentage: 11.5
Residents reviewed for weight loss: 4
Residents reviewed for hospitalizations/diagnostic services: 3
Inspection Report
Routine
Deficiencies: 3
Date: Jan 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care, fall prevention, and urinary tract infection prevention in a nursing home facility.
Findings
The facility failed to notify nursing staff of a new pressure ulcer, implement adequate fall prevention interventions for multiple residents, and properly handle urinary drainage bags to prevent infections. Several residents experienced falls and pressure injuries due to inadequate supervision and care.
Deficiencies (3)
F 0686: The facility failed to notify the nurse of a new open pressure ulcer wound for 1 of 3 residents reviewed for pressure wounds. The wound was first noted on the day of inspection.
F 0689: The facility failed to implement interventions to prevent falls for 3 of 3 residents reviewed for falls, resulting in multiple fall incidents with injuries and inadequate supervision.
F 0690: The facility failed to handle a urinary drainage bag properly for 1 of 4 residents reviewed, allowing the bag to touch the floor and be held above bladder level, increasing infection risk.
Report Facts
Residents reviewed for pressure wounds: 3
Residents reviewed for falls: 3
Residents reviewed for urinary tract infections: 4
Fall incidents reported for resident R4: 14
Length of laceration for R2 fall injury: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing (DON) | Commented on care plan interventions and urinary drainage bag handling |
| V7 | Licensed Practical Nurse (LPN) | Notified about pressure ulcer and call light placement for resident R2 |
| V12 | Certified Nursing Assistant (CNA) | Performed incontinence care and transferred residents; involved in catheter bag handling |
| V6 | Certified Nursing Assistant (CNA) | Assisted with transfers and catheter bag handling |
| V16 | Certified Nursing Assistant (CNA) | Assisted resident R3 during fall incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error where a resident (R1) was administered another resident's medications, resulting in hospitalization.
Complaint Details
The complaint investigation found that resident R1 received medications intended for another resident, leading to hospitalization in an intensive care unit. The medication error was substantiated and caused actual harm.
Findings
The facility failed to administer the correct medications to resident R1, causing severe adverse effects including hypotension and requiring transfer to an intensive care unit. The error was attributed to a nurse administering medications from the wrong Medication Administration Record (MAR).
Deficiencies (1)
F 0760: Ensure that residents are free from significant medication errors. The facility administered incorrect medications to resident R1, resulting in actual harm and hospitalization.
Report Facts
Residents affected: 4
Residents affected: 1
Medication error report date: Mar 22, 2023
Blood pressure reading: 66
Blood pressure reading: 45
Blood pressure reading: 78
Blood pressure reading: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Licensed Practical Nurse (LPN) | Nurse who administered the wrong medications to resident R1 |
| V2 | Director of Nursing | Provided expectations on medication administration procedures |
| V9 | Physician Assistant | Explained the potential effects of the medication error on resident R1 |
| V4 | Licensed Practical Nurse (LPN) | Commented on importance of double and triple checking medications |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 16, 2023
Visit Reason
The inspection was a routine survey to assess compliance with federal and state regulations regarding resident privacy, pressure ulcer care, catheter care, respiratory care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during care, inadequate pressure ulcer prevention and treatment, improper catheter care, unlicensed personnel administering oxygen, and poor infection control practices such as improper glove use and disposal of soiled linens.
Deficiencies (5)
F 0583: The facility failed to ensure a resident was provided privacy during care when window coverings remained open during incontinence care for 1 of 1 resident reviewed.
F 0686: The facility failed to provide appropriate pressure ulcer care by not identifying an area of pressure prior to becoming unstageable, delaying wound assessment, and failing to reposition a resident for 5 hours with a stage 4 pressure ulcer for 2 of 5 residents reviewed.
F 0690: The facility failed to ensure a resident's urinary drainage bag was positioned to prevent cross contamination for 1 of 4 residents reviewed for catheters.
F 0695: The facility failed to have a Licensed Nurse administer oxygen to a resident as required by policy for 1 of 16 residents reviewed for oxygen.
F 0880: The facility failed to dispose of soiled linens properly and failed to remove gloves after providing incontinence care and after removing a soiled wound dressing for 2 of 16 residents reviewed for infection control.
Report Facts
Residents reviewed for privacy: 16
Residents reviewed for pressure ulcers: 16
Residents reviewed for catheters: 16
Residents reviewed for oxygen: 16
Residents reviewed for infection control: 16
Pressure ulcer size: 5
Pressure ulcer size: 4.5
Repositioning interval missed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding privacy, pressure ulcer care, catheter care, oxygen administration, and infection control policies. |
| V4 | Licensed Practical Nurse | Provided statements regarding oxygen administration and infection control practices. |
| V5 | Certified Nursing Assistant | Observed assisting residents with oxygen and incontinence care; involved in findings related to improper glove use and linen disposal. |
| V3 | Licensed Practical Nurse | Observed performing wound dressing change with improper glove use. |
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