Haven of Champaign

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary environment by failing to address ongoing water intrusion and deterioration of building materials throughout the facility. This failure has the potential to affect all 57 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to complete neurological assessments post head injury per facility policy for one resident (R1) reviewed for accident/incident on the sample list of 12 residents.

Inspectors wroteBased on interview and record review the facility failed to record and maintain documentation for food temperatures taken prior to meal service and temperatures of refrigerator and freezers used to store facility food. This failure has the potential to affect all 50 residents residing in the facility. Findings Include: The Service of Food policy, last revised in June 2023, documents foods will be held between 135- and 140-degrees Fahrenheit or higher for service. Food temperatures should be taken on the food service line by the culinary team prior to serving each meal and recorded in a temperature logbook. On 2/22/26 at 1:15 PM V8 [NAME] confirmed he did not document food service line temperatures on the log sheets for that day's noon meal. V8 also confirmed there were other meals on the log with no temperatures documented. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food to six residents (R31, R20, R19, R7, R28, R10) that was attractive palatable, and in a form, they could easily consume of 37 residents reviewed for dining in a sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents with dignity and respect, and provide care for each resident in a way that promotes their quality of life. This failure affected three of three residents (R3, R12, R18) reviewed for dignified care on the sample list of 37. Findings Include: The Facility's Resident Rights for People in Long-Term Care Facilities policy dated November 2018 documents the facility must treat each resident with dignity and respect and must care for each resident in a manner that promotes their quality of life. 1. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact and requires staff assistance for showering, transfers, hygiene and toileting. On 2/22/26 at 9:33 AM R3 stated she does not like how the staff always rush through things when providing her care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary feeding assistance for a resident who was observed eating with his hands. This failure affected one (R4) of three residents reviewed for nutrition from a total sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess residents using antipsychotics, failed to identify and track resident specific targeted behaviors, and failed to follow physician's order for gradual dose reduction for three residents (R43, R13, R2) of five residents reviewed for psychotropics in a sample list of 37 residents. Findings Include: 1. R43's Medication Administration Record (MAR) for February 2026 includes a current order initiated 1/29/26 for Seroquel Oral Tablet 25 mg (Quetiapine Fumarate): give 1 tablet by mouth two times a day for Major Depressive Disorder and Anxiety. On 2/22/26 at 9:15 a.m., R43 was seated in a wheelchair in her room. R43 reached down with her right hand several times as though she was picking something up from the floor. There was nothing visible that she was reaching for. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a care plan to address a resident's hearing loss and implement interventions to maintain or improve his communication for one of 16 (R20) residents reviewed for care plans in the sample of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided appropriate intervention to assist a resident with moderate hearing loss to communicate his needs effectively for one of one resident (R20) reviewed for hearing loss in the sample of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders for oxygen for three residents (R22, R33, R55) of three residents reviewed for oxygen in a sample list of 37. Findings Include: 1. R55's Physician's Order Sheet (POS) includes an order dated 12/8/25 for oxygen at two liters per minute as needed. R55's progress notes document that R55 received oxygen on 12/8/26 at three liters per minute from 1:38 PM until 11:39 PM. There is no physician's order authorizing oxygen at three liters per minute for R55. On 2/24/26 at 1:13 PM, V2, Director of Nursing, verified that R55's oxygen was increased to three liters per minute without a physician's order. V2 stated, The nurse increased the oxygen flow rate when R55's oxygen saturation went lower and he became short of breath. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to maintain expanded barrier precautions (EBP) for one resident (R25) who has open wounds of five residents reviewed for EBP in a sample list of 37.

Inspectors wroteBased on interview and record review the facility failed to complete infection surveillance documentation and ensure one resident (R25) met the criteria for initiation of an antibiotic of four residents reviewed for antibiotic stewardship in a sample of 37 residents. Findings Include:R25's Care Plan initiated 2/22/26 includes the following diagnoses: Presence of Left Artificial Hip Joint, Presence of Cardiac Pacemaker, Malignant Neoplasm of Abdomen, Cataract, Atrial Fibrillation and Flutter, Hypertension, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Wound of Left Great Toe, Peripheral Vascular Disease, and Chronic Kidney Disease Stage III. R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. R25's Wound assessment dated [DATE] documents R25 has an unstageable pressure ulcer in his left heel and left great toe. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse coverage for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 50 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively manage resident's pain according to physician orders, the resident care plan, and the resident's preference. This failure affects one resident (R1) out of three reviewed for pain on the sample list of five. This failure resulted in a decline in R1's ability to participate in routine activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a procedure with a mechanical lifting device in a safe manner to prevent a resident fall. This failure affects one resident (R1) out of five reviewed for falls and mechanical lift use on the sample list of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to acquire, dispense, and administer a resident's pain medication as ordered by the physician. This failure affects one resident (R1) out of three reviewed for pain on the sample list of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to respect residents' right to be treated with dignity and respect for seven (R10, R31, R19, R29, R37, R45, R57) of seven residents reviewed for resident rights in the sample list of 39. This failure resulted in psychosocial harm of R10 and R57 causing R10 and R57 to be visibly upset and tearful.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow up on grievances and document actions taken for six (R19, R29, R36, R37, R45, R57) of six residents reviewed for grievances in the sample list of 39. This failure has the potential to affect all 51 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to employ a Director of Nursing and failed to provide the services of a registered nurse for eight consecutive hours seven days a week. This failure has the potential to affect all 51 residents residing in the facility. Findings Include: On 3/9/25, 3/10/25 and 3/11/25 there was not a full time Director of Nursing working in the facility. The resident roster dated 3/9/25 documents 51 residents reside at the facility. The facility's nursing working schedule from 2/24/25 to 3/10/25 documents the facility did not have the services of a Registered Nurse (RN) for eight consecutive hours on 2/24/25, 2/27/25, 2/28/25, 3/1/25 and 3/2/25. On 3/10/25 at 9:00am V3 Assistant Director of Nursing stated the facility has not had a Director of Nursing (DON) since 1/31/25 when the pervious Director of Nursing took another job. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 51 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ dietary support staff with the appropriate competencies to carry out the functions of the food and nutrition service. This failure has the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to annually implement and evaluate the effectiveness of a performance improvement plan. This failure has the potential to affect all 51 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to have quarterly Quality Assurance meetings. This failure has the potential to affect all 51 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their water management plan, prevent potential cross contamination of a pressure sore and the treatment cart, and implement Enhanced Barrier Precautions. These failures have the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents have access to their personal funds for four (R57, R14, R19, R37) of seven residents reviewed for personal funds in the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to provide quarterly statements for personal fund accounts for four (R1, R7, R14, R18) of seven residents reviewed for personal funds in the sample list of 39.

Inspectors wroteBased on interview and record review, the facility failed to provide numerous showers as scheduled for dependent residents. These failures affect two residents (R9, R43) of three reviewed for activities of daily living in the sample list of 39. 1. On 3/9/25 at 9:00am R10 stated that R9 is R10's Husband and R9 does not get two showers a week. R10 stated that R9 needs help from staff to get a shower, due to R9's not knowing how to take one without someone helping R9. On 3/11/25 at 9:15am V3 Assistant Director of Nursing (ADON) stated all residents are scheduled for two showers a week, and if a resident refuses a shower after three attempts a bed bath is offered. V3 stated if the resident still refuses, a nurse is notified and documents it in the resident's chart. V3 stated after giving the resident a shower, the Certified Nursing Assistant (CNA) documents it on a shower sheet. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer immunization education, immunization consent forms, and vaccinations for five residents (R9, R28, R41, R52, R160) of five residents reviewed for immunizations in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a physician order for medication found at the bedside for one (R39) of one resident reviewed for self administration of medications in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician's ordered treatments, monitor daily weights, report weight gain, and develop a care plan for lymphedema and congestive heart failure (CHF) for one (R10) of two residents reviewed for edema in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a treatment order for a newly discovered pressure area, monitor the area and follow manufactures recommendations for a treatment application for one resident (R43) of two residents reviewed for pressure ulcers in the sample list of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide complete and hygienic catheter care, failed to maintain the urinary catheter tubing and drainage bag off the floor, failed to have a physician order for a urinary catheter and failed to record catheter care and urinary output for two (R31, R36) of two residents reviewed for urinary catheters in the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to implement gradual dose reductions (GDR), identify and track targeted behaviors, implement nonpharmacological interventions, and assess for the use of psychotropic medications for one of five residents (R14) reviewed for unnecessary medications in the sample list of 39.

Inspectors wroteBased on observation,interview and record review the facility failed to administer medications according to physician orders and manufacturer recommendations for two of five residents (R30 and R31) reviewed for medication administration on the sample of 39. The facility had two errors out of 28 opportunities resulting in a medication error rate of 7.14 percent.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a diet order for thickened liquids for one (R210) of 24 residents reviewed for meals in the sample list of 39.

Inspectors wroteBased on interview and record review the facility failed to staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to have adequate dietary staff to ensure meals are served timely. This failure affects four (R1, R4, R5, R6) of five residents reviewed for meals in the sample list of 13. This failure has the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen. This failure has the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus Infection) by failing to maintain a supply of N95 respirators, ensure staff wear appropriate Personal Protective Equipment (PPE), ensure staff wear PPE correctly, and routinely disinfect high touch surfaces during a COVID-19 Outbreak. This failure affects seven (R3, R5, R2, R10, R11, R12, R13) of seven residents reviewed for Infection Control in the sample list of 13. These failures have the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain functioning call lights for four (R3, R5, R8, R9) of four residents reviewed for call lights in the sample of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to sufficiently staff housekeepers in order to provide a clean and homelike environment. This failure affects three (R2, R5, R6) of seven residents reviewed for housekeeping in the sample list of 13.

Inspectors wroteBased on interview and record review the facility failed to provide scheduled showers for one (R4) of seven residents reviewed for Activities of Daily Living in the sample list of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a physician ordered diet for one (R1) of five residents reviewed for diet in the sample list of 13.

Inspectors wroteBased on interview and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to employ sufficient staffing with the appropriate competencies to provide food service. This failure has the potential to affect all 49 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect two (R1 and R2) of three residents from verbal and mental abuse from a total sample of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to implement its abuse policy by failing to immediately report suspected abuse to the abuse coordinator and failing to ensure that the alleged abuser was immediately removed from the facility for two (R1 and R2) of three residents reviewed for abuse from a total sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 47 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to have qualified dietary aides and a cook. This failure has the potential to affect all 47 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to administer a dietary supplement according to physician's orders for one resident (R3) of one resident reviewed for following physician's orders in the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from verbal and mental abuse by a staff member. This failure affected one of four residents (R1) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. The facility is committed to protecting the residents from abuse. Abuse includes the willful intimidation resulting in mental anguish which can include verbal or mental abuse. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse includes humiliation. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on four of eighteen days reviewed for RN staffing. This failure has the potential to affect all 49 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the range hood in a sanitary condition to protect food being prepared on the range, and failed to maintain the commercial dishwasher sanitizer levels to sanitize meal service wares and utensils. These failures have the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to conduct quarterly Quality Assurance (QA) meetings. This failure has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to answer call lights in a timely manner for seven residents (R21, R29, R31, R37, R39, R40, R46) and failed to provide privacy while giving an insulin injection in the dining room for one resident (R40) of eight residents reviewed for dignity in the sample list of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label insulin pens after opening for five residents (R5, R15, R16, R27, R40) of five residents reviewed for insulin storage in the sample list of 32. R5's Physician Order Sheet (POS) dated 5-1-2024 - 5-31-24, documents Insulin Glargine-YFGN Units 100 inject 15 units subcutaneous (SQ) two times a day; Fiasp 100 units/milliliter (ml) 3 ml pen inject 5 units SQ three times daily before meals and Insulin Fiasp 100ml 3 ml per sliding scale four times a day. R15's POS dated 5-1-2024 - 5-31-24, documents Insulin Glargine -YFGN U100 inject 15 units SQ at bedtime, Insulin Lispro 100units/ml inject four times a day per sliding scale. R16's POS dated 5-1-2024 - 5-31-24, documents Insulin Lispro 100u/ml SQ before meals four times a day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food served was palatable and attractive. This failure affects seven (R21, R29, R31, R37, R39, R40, R46) residents reviewed for dining services.

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with an Advance Beneficiary Notice (ABN) at the termination of a Medicare Part A covered stay, thereby nullifying the resident's right to continue therapy services at their own expense, or decline therapy services. This failure affects one resident (R5) out of a sample of three reviewed for Beneficiary Notices on the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to report and notify the Administrator and a supervisor of injuries of unknown origin and failed to notify the administrator of a resident to resident incident for three of three (R11, R31 and R17) residents reviewed for Abuse Allegations in the sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to complete comprehensive Minimum Data Set assessments (Resident Assessment Instrument) in the required time frames. This failure affects two residents (R14 and R39) out of two reviewed for assessment timing on the sample list of 32.

Inspectors wroteBased on interview and record review, the facility failed to encode and transmit residents' Minimum Data Set Assessments (Resident Assessment Instrument) within the required time frame. This failure affects two residents (R14 and R39) out of two reviewed for assessment transmissions on the sample list of 32.

Inspectors wroteBased on interview and record review, the facility failed to encode residents' Minimum Data Sets (Resident Assessment Instrument) to accurately reflect residents' health status. This failure affects two residents (R13, R34) out of ten reviewed for Minimum Data Set accuracy on the sample list of 32.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Level 2 Pre-admission Screening and Resident Review (PASARR) for a resident diagnosed with severe mental illness while residing in the facility. This failure affects one resident (R40) out of three reviewed for Pre-admission Screening on the sample list of 32.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its shower and bathing policy and procedures to ensure all residents received a bath/shower at least once a week. This failure affects two residents (R21 and R23) out of 3 residents reviewed for activities of daily living assistance from a total sample list of 32.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders in obtaining oxygen saturation levels and documenting them on the residents Treatment Administration Record (TAR). This failure affects one resident (R23) reviewed for following physician orders from a total sample list of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to correctly perform supra pubic catheter care for one of one residents (R101) reviewed for catheter care in the sample list of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve a physician ordered diet texture to a resident who required mechanically altered food. This failure affects one resident (R18) out of ten reviewed for diet textures on the sample list of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure therapy services were provided for three (R1, R2, R3) of three residents reviewed for therapy services on the sample list of six.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive care plan in the required twenty-one days after admission to the facility. This failure affects one resident (R1) on the sample of three reviewed for falls.

Inspectors wroteBased on interview and record review the facility failed to revise a care plan for one (R2) of three residents reviewed for fall care plans.

Inspectors wroteBased on interview and record review the facility failed to conduct a fall assessment, failed to implement interventions to prevent falls, and failed to properly assess the resident after a fall for one (R3) of three residents reviewed for falls.

Inspectors wroteBased on interview and record review the facility failed to have an infection control program based on current standards including; maintaining infection control records, following guidelines for employees returning to work, testing for Covid-19 as recommended and reporting outbreaks as directed. This failure has the potential to affect all 52 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to have an infection preventionist on staff, responsible for the infection control program. This failure has the potential to affect all 52 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to offer and or provide influenza, pneumonia and Covid-19 vaccinations to three (R1, R3 and R4) of five residents reviewed for immunizations from a total sample list of five residents.