The Haven of Bement.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the residents' right to be free from verbal and physical abuse by another resident for two of four residents (R18, R23) reviewed for abuse on the sample list of 27. This failure resulted in R23 experiencing physical pain, distress, and fear after R44 hit R23 in the stomach on three separate occasions. 1. R23's Census Detail and Medical Diagnoses List dated 3/10/26 documents R23 was admitted to the facility 11/3/25 with medical diagnoses including Cerebral Vascular Accident with Physical Symptoms, Quadriplegia, Anxiety, and Contractures. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure quarterly Quality Assurance meetings were held, and failed to ensure the Director of Nursing attended the Quality Assurance meetings. This failure affects all 36-residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use, systems to monitor antibiotic outcomes, resistance, and adverse events, and use of standardized tools and criteria to assess resident infections. This failure has the potential to affect all 36 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed repeatedly to report allegations of resident-to-resident verbal abuse, to the Illinois Department of Public Health. This failure affects two of four residents (R15 and R18) reviewed for abuse on the sample list of 27.

Inspectors wroteBased on interview and record review the facility failed repeatedly to investigate reported allegations of witnessed resident-to-resident verbal abuse and failed to remove the alleged perpetrator, in a timely manner. This failure affects two of four residents (R15 and R18) reviewed for abuse on the sample list of 27.

Inspectors wroteBased on interview and record review, the facility failed to provide timely assistance for incontinence cares to four residents (R11, R12, R22, R35) of four reviewed for Activities of Daily Living in the sample list of 27 residents.

Inspectors wroteBased on interview and record review the facility failed repeatedly to maintain complete and accurate medical records by failing to document incidence of resident to resident altercations. This failure affected two of four residents ( R15 and R18) reviewed for abuse on the sample list of 27.

Inspectors wroteBased on interview and record review, the facility failed to have a physician document in the medical record documenting the basis of a resident's discharge, the specific needs the resident has that cannot be met in the facility, the attempts the facility made to meet those needs, and services available at the receiving facility to meet the resident's need. This failure affects one resident (R44) out of three reviewed for discharge on the sample list of twenty-seven.

Inspectors wroteBased on interview and record review, the facility failed to include required information regarding advocacy agencies in an involuntary discharge notice. This failure affects one resident (R44) out of three reviewed for discharge on the sample list of 27.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's bed wheels were locked for one resident (R2) out of three residents reviewed for falls in a sample of 27 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to wear Personal Protective Equipment (PPE) to provide care, for a resident on droplet precautions due to Methicillin-resistant Staphylococcus Aureus (MRSA) infection. This failure affects one of one resident (R3) reviewed for transmission-based precautions on the sample list of 27.

Inspectors wroteBased on Interview and record review the facility failed to replace misappropriated goods in a reasonable time frame for one (R3) of three residents reviewed for misappropriation. R3 was upset and angered of having to replace (ear buds) with R3's own personal money and the facility not reporting this to the police as R3 wanted to press charges. This failure to report to the police and to replace the goods in a timely fashion resulted in psychosocial harm to R3. Findings Include:The Facilities Abuse Prevention Policy Dated 1/25 documents that the facility affirms the right of the resident to be free from misappropriation of property, deprivation of goods and services by staff or mistreatment. This policy also documents that the facility would keep the resident informed of the conclusions of the investigations. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately assess a resident for weight loss for one (R1) of three residents reviewed for nutrition. A significant weight loss was not identified, and interventions were not put in place to prevent further weight loss resulting in R1 being admitted to the hospital with a diagnosis of Hypokalemia due to malnutrition/dehydration.

Inspectors wroteBased on interview and record review the facility failed to have a policy to verify the identity of agency staff to ensure one (V28) of three CNA's (V18, V19) reviewed demonstrated competency in the skills and techniques necessary to care for residents. This failure resulted in a facility wide failure and effected all 39 residents in the building. Findings Include:The facility's Certified Nursing Job Description revised on 10/11/2024 documents, qualifications to perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements are to have a current certification as a Certified Nursing Assistant in accordance with the laws of the State of Illinois. On 1/9/2026 at 5:00PM, (Local County Sheriffs) were called to the facility for an altercation between two employees (V19 and V28). [...]

Inspectors wroteBased on Interview and Record Review the Facility failed to ensure Registry verification for one (V28) of three staff members reviewed for certification. This failure resulted with one (V28) working as a Certified Nursing Assistant while not certified. This failure affected all 39 residents residing at the facility. Findings Include: On 1/9/2026, V28 Certified Nursing Assistant (CNA) came to the facility and began working under the name of V20 CNA who was scheduled to work a shift at the facility as a Certified Nursing Assistant. After having a verbal altercation with V19 CNA, V28 confirmed that V28's identity was not V20. On 1/15/2026 at 11:05AM, V1 Administrator stated the facility uses a contracted agency to provide certified staff for employment as needed. V1 stated that V20 was scheduled to work 1/9/26. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the physician and family of the resident with a change in condition (weight loss) for two (R1, R8) of three residents reviewed for weight loss.

Inspectors wroteBased on interview, and record review the facility failed to report an altercation between two (V19 and V28) employees in presence of three (R6, R9 and R10) residents and failed to report that an unqualified individual was working as a Certified Nursing Assistant.

Inspectors wroteBased on Interview and Record Review the facility failed to report to the police the misappropriation of ear buds in a timely manner for one (R3) of three residents on the sample list. Findings Include: On 11/6/2025 at 9:30PM, R3 reported to staff that R3's (ear buds) were missing from R3's room and the facility reported the misappropriation of goods to the state agency. On 11/14/2025 the final report from the state agency documents that on 11/6/2025 R3 went to put in R3's (ear buds) into the ear canal that R3 kept in a specific place when R3 realized the (ear buds) were not there. R3 utilized the (tracking) function on R3's cellular phone and the (ear buds) were pinged (located) at an address in (about 30 miles away). R3 asked one of the Certified Nursing Assistant on shift what her address was. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain transport equipment in working order and failed to safely secure one resident (R1) by not applying a seatbelt properly during resident transport. R1 experienced pain and obtained two nasal fractures and six sutures after falling while being transported in the facility van. The facility failed to implement fall interventions and failed to determine root causes for four falls for one (R3) resident. These failures affected two (R1, R3) residents out of three residents reviewed for Accidents in a sample list of three residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse for eight consecutive hours seven days per week. This failure has the potential to affect all 39 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to monitor urine characteristics, timely report changes in urine and urine culture results to the provider, and implement infection control measures to prevent catheter associated urinary tract infections (CAUTI) for one (R32) of two residents reviewed for UTIs in the sample list of 30. These failures resulted in delayed treatment of R32's CAUTI and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to sufficiently staff certified nursing assistants (CNAs). This failure affects four (R4, R18, R22, R31) of 16 residents reviewed for staffing in the sample list of 30. This failure has the potential to affect all 32 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to staff a full time Director of Nursing (DON). This failure has the potential to affect all 32 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to document registry verifications of nurse aide competency for five newly hired nurse aides prior to beginning employment in the facility. This failure has the potential to affect all 32 residents residing in the facility.

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 32 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary food storage areas. This failure has the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to implement surveillance monitoring of resident infections and implement corrective measures, and failed to develop a water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. These failures have the potential to affect all 32 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to implement its antibiotic stewardship policy by failing to evaluate clinical data to ensure infection criteria and appropriate use of antibiotics. This failure has the potential to affect all 32 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to document and follow up on grievances for five (R4, R14, R18, R22, R31) of five residents reviewed for grievances in the sample list of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve pureed diets as planned on the menu. This failure affects three residents (R2, R7, R13) of four reviewed for pureed diets in the sample list of 30.

Inspectors wrote3.) On 12/09/24 at 9:52 AM R8 was in R8's room and had approximately 1/4 inch long facial hair to chin and upper lip. On 12/9/24 at 3:02 PM R8's facial hair remained to upper lip and chin. On 12/10/24 at 1:23 PM R8 was in the dining room and facial hair remained to upper lip and chin. R8's Minimum Data Set (MDS) dated [DATE] documents R8 requires partial/moderate assistance for personal hygiene. R8's care plan dated 5/15/24 documents R8 has self care deficit with activities of daily living and prefers to have facial hair removed. This care plan includes to provide showers one to two times per week and ask resident preference, and assist R8 with grooming/shaving facial hair on shower days and as needed. R8's care plan does not document R8 is resistive to cares. The facility's master shower schedule documents R8's showers are scheduled on Wednesdays and Saturdays. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to perform a mechanical lift transfer safely for one (R8) of one residents reviewed for transfers in the sample list of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to replace an oxygen mask weekly, failed to store respiratory equipment in a manner to prevent cross contamination, failed to follow an intervention to re-insert a tracheostomy, failed to ensure a replacement tracheostomy was kept at bedside, and failed to administer oxygen per physician's order for two (R23, R24) of four residents reviewed for respiratory care on the sample list of 30.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available and administered as ordered resulting in significant medication errors for two (R8, R18) of 10 residents reviewed for medication administration in the sample list of 30.

Inspectors wroteBased on interview and record review the facility failed to offer pneumococcal vaccinations and maintain vaccination documentation for three (R18, R19, R22) of five residents reviewed for immunizations in the sample list of 30.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of medication for one resident (R1) of three residents reviewed for medications in the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to investigate a report of misappropriation of resident medication for one resident (R1) of three residents reviewed for medications in the sample list of four.

Inspectors wroteBased on interview and record review, the facility failed to administer seizure medications to a resident with a seizure disorder requiring scheduled therapeutic medication monitoring. This failure affects one resident (R1) of three residents reviewed for significant medication errors in the sample list of four.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of a resident's physical change of condition. This failure affects one of three residents (R1) reviewed for nursing care in the sample of three. Findings Include: The facility's Notification for Change in Resident Condition or Status dated 12/7/17 documents the facility staff shall promptly notify appropriate individuals (medical provider) of changes in the resident's medical/mental condition and/or status. R1's Medical Diagnoses list dated September 2024 documents R1 is diagnosed with Dementia, Covid-19, Heart Failure, Dissociative and Conversion Disorder, Major Depression, and Lewy Body Dementia. R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from physical abuse by another resident for two residents (R1, R2) of three reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to document a resident-to-resident physical abuse incident and investigation in a resident's medical record. This failure affects one resident (R2) of three reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure therapy services were provided for five (R1, R2, R3, R4 and R5) of five residents reviewed for therapy services from a sample list of five residents.

Inspectors wroteBased on record review and interview the facility failed to provide a written Notice of Medicare Non-Coverage notice, (NOMNC) for two (R4 and R5) of three residents reviewed for Medicare Non-Coverage notices at least 48 hours prior to discharge from Medicare from the total sample list of five.

Inspectors wroteBased on interview and record review the facility failed to use the services of an RN eight consecutive hours Seven days a week and failed to designate a Registered Nurse to serve as a full-time Director of Nursing. This failure has the potential to affect all residents who reside at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper food storage and labeling to prevent potential food spoilage and resident illness. This failure has the potential to affect all 31 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to have an Infection Preventionist working at the facility and overseeing the infection control program This failure has the potential to affect all 31 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the dignity of five (R11, R5, R6, R12, R17 and R27) of five residents reviewed for dignity from a total sample list of 24 residents reviewed.

Inspectors wroteBased on interview and record review the facility failed to document the organisms being treated prior to initiating and/or continuing antibiotic therapy for four of four residents (R26, R85, R86, R29) reviewed for antibiotic stewardship in a sample list of 24.

Inspectors wroteBased on interview and record review the facility failed to follow Physician orders to obtain daily weights for two residents with a diagnosis of Congestive Heart Failure for two of two residents (R24, R5) reviewed for Edema in the sample list of 24.

Inspectors wroteBased on interview and record review, the facility failed to provide Passive Range of Motion (PROM) to one resident (R28) admitted with contractures of one resident reviewed for Restorative Nursing in a sample list of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to properly manage a tracheostomy tube for one (R22) of one residents reviewed for tracheostomy tubes from a total sample list of 24 residents reviewed.

Inspectors wroteBased on interview and record review the facility failed to provide required physician's visits for one resident (R28) of one resident reviewed for physician's visits in a sample list of 24. Findings Include: R28's Physician's Order Sheet (POS) includes the following diagnoses: Spastic Quadriplegic Cerebral Palsy, Epilepsy, Malnutrition, Cortical Blindness, and Profound Intellectual Disabilities. The facility's Daily Midnight Census documents R28 was admitted to the facility on [DATE]. R28's admission orders and initial assessment were completed by the Nurse Practitioner. R28's Progress Notes document R28 was evaluated by the Nurse Practitioner monthly since admission. The first evaluation by V15, Medical Director is documented as 12/24/23 at 10:00AM. On 10/10/24 at 2:00PM V1, Administrator stated The company who provides our medical Director is in Chicago. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered to keep the medication error rate below five percent (5%). There were two medication errors out of 25 opportunities resulting in a 8% error rate. This failure affects two residents (R13, R17) of seven residents reviewed for medications on the sample list of 24.

Inspectors wroteBased on interview and record review the facility failed to prevent a significant medication error for one resident (R28) of seven residents reviewed for medication in a sample list of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the most up to date survey inspection results for residents and families review. This failure has the potential to affect all 31 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to supervise a resident during toileting, failed to implement a post fall intervention for staff training, and failed to complete a fall investigation for two of three residents (R1, R3) reviewed for falls on the sample list of three.