The Haven on the River

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free from neglect for 1 of 6 residents (R1) reviewed for neglect in the sample of 12. The failure resulted in R1 not receiving an immediate nursing assessment and treatment for a fall resulting in a hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to provide administrative oversight to ensure the facility implemented their policy to facilitate cooperation with regulatory bodies in connection with IDPH (Illinois Department of Public Health) surveys. This failure has the ability to affect all 45 residents living at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately initiate an investigation into a resident fall and failed to ensure a door remained closed to prevent elopements from residents at risk for elopement for 7 or 7 residents (R1, R4, R8, R9, R10, R11, R12) reviewed for accidents and supervision in a sample of 12.

Inspectors wroteBased on record review and interview, the facility failed to notify a residents POA (Power of Attorney) and Nurse Practitioner of a fall and a decrease in oxygen saturation for 1 of 3 residents (R1) reviewed for notification in a sample of 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medication was available for 1 of 3 (R1) residents reviewed for pain in the sample 10. This failure resulted in R1's pain not being controlled post knee replacement surgery, causing R1 to become restless and anxious. R1 stated when he doesn't have the pain medication he doesn't move as much because of the pain. Findings Include:R1's admission Record, with a print date of 4/14/26, documents R1 was admitted to the facility on [DATE], with diagnoses that include infection and inflammatory reaction due to internal right knee prosthesis, after care following knee joint prosthesis, fracture of right patella, depression, anxiety, heart failure, and seizures. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medication was available for administration as ordered and antibiotics were administered timely for 1 of 3 (R1) residents reviewed for pharmacy services in the sample of 10. Findings Include:1. R1's admission Record, with a print date of 4/14/26, documents R1 was admitted to the facility on [DATE] with diagnoses that include infection and inflammatory reaction due to internal right knee prosthesis, after care following knee joint prosthesis, fracture of right patella, depression, anxiety, heart failure, and seizures. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure antibiotics were administered as ordered by the physician for 1 of 3 (R1) residents reviewed for medication administration in the sample of 10. Findings Include:R1's admission Record, with a print date of 4/14/26, documents R1 was admitted to the facility on [DATE] with diagnoses that include infection and inflammatory reaction due to internal right knee prosthesis, after care following knee joint prosthesis, fracture of right patella, depression, anxiety, heart failure, and seizures. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R1 is cognitively intact. This same MDS documents R1 had a recent knee replacement surgery. R1's current Care Plan documents a Focus area of, The resident has infection of the right knee prosthesis. Date Initiated: 03/28/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed respond to a pharmacy review for an as needed psychotropic medication and failed to document the indication of use for the psychotropic medication for 1 of 3 resident (R2) reviewed for chemical restraints in a sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hot water for showers and personal care for 8 of 8 residents (R1, R2, R4, R5, R6, R11, R13, R14) reviewed for environment in a sample of 14. Findings Included:On 2/21/26 at 8:30 AM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/_ 2 degrees Fahrenheit. 1. On 2/21/26 at 9:30 AM, the North Hall Shower water temperature was taken at the shower head with a metal stemmed thermometer and the hot water measured 72 degrees Fahrenheit. The temperature of the hot water at the sink registered 95.3 degrees Fahrenheit 2. On 2/21/2026 at 9:35 AM, R6's and R13's bathroom sinks hot water temperature was taken with a metal stemmed thermometer and registered 95.5 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders and failed to assess and monitor a resident's declining condition for 1 of 3 residents (R1) reviewed for quality of care in a sample of 18. This failure resulted in R1's hospital admission for acute kidney injury and hyperkalemia requiring emergent dialysis and subsequent death. This failure resulted in Immediate jeopardy, which was identified to have begun on 12/28/25 when the facility failed to obtain physician ordered labs of CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and TSH (Thyroid-stimulating hormone) for R1. The facility failed to follow up on UA (Urinalysis) and Culture and Sensitivity lab results that was ordered for R1 on 12/28/25. The facility failed to notify the physician of a decline in R1's condition. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure has the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a resident's right to receive timely care and be treated with dignity for 4 of 18 residents (R2, R5, R6 and R12) reviewed for resident rights in a sample of 18. This failure has the potential to affect 26 residents residing on the North Hall.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that includes post fall assessment and treatment, monitoring, reporting, and investigating for 1 of 3 residents (R1) reviewed for quality of care in the sample of 6. This failure resulted in R1 falling and sustaining a hip and femur fracture without timely assessment and treatment after the fall. A reasonable person would experience feelings of discomfort and distress due to not receiving timely after fall care. This past non-compliance occurred between 11/14/25 and 11/16/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was properly assessed for injury and pain and to address resident complaints of pain post fall for 1 of 3 (R1) residents reviewed for pain in a sample of 6. R1 fell and sustained a hip and femur fracture without proper assessment of injury/pain. A reasonable person would experience feelings severe pain and discomfort due to not receiving pain relief medication.

Inspectors wroteBased on interview and record review, the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for accidents in a sample of 5. This failure resulted in R1 falling from the lifting machine, hitting her head and receiving three staples to repair a 1.2 cm (centimeter) laceration to the back of her scalp. This past non-compliance occurred between 9/14/2025 and 9/15/25.

Inspectors wroteBased on interview and record review, the facility failed to administer prescribed medications at the prescribed time. This failure has the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide medical records requested to aide in the survey process for 2 of 2 residents (R3 and R4) reviewed for medication administration in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure resident care needs are met. This failure has the potential to affect all 47 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to change an indwelling urinary catheter per physician's orders for 1 of 3 residents (R1) reviewed for urinary catheters in a sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment was accurately coded for 1 (R9) of 1 resident reviewed for accuracy of assessments in the sample of 28. Findings Include: R9's admission Record documented R9 as a 71 -year -old, with an admission date of 02/22/2024 to the facility. Diagnoses listed are unspecified atrial fibrillation, type 2 diabetes mellitus, edema, primary osteoarthritis of left knee, obesity, venous insufficiency, poly osteoarthritis, pain in leg, and unspecified osteoarthritis. R9's Illinois PASRR (Preadmission Screening and Resident Review) Summary of Findings, dated 03/22/2024, documented, Level II Outcome- Approved No SS (Specialized Services). R9's MDS with an Assessment Reference Date of 07/02/2024 documented this MDS as being an annual assessment. Section A1500. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure wound treatment per physician's orders for one resident (R31) of three residents reviewed for pressure wounds in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to provide range of motion services to 1 (R9) of 1 resident reviewed for range of motion in the sample of 28. Findings Include: R9's admission Record documented R9 as a 71 -year -old with an admission date of 02/22/2024 to the facility. Diagnoses listed are unspecified atrial fibrillation, type 2 diabetes mellitus, edema, primary osteoarthritis of left knee, obesity, venous insufficiency, poly osteoarthritis, pain in leg, and unspecified osteoarthritis. R9's Physician's orders, with a print date of 05/15/2025, do not document an order for any range of motion or restorative nursing program. R9's Quarterly MDS (Minimum Data Set), with a date of 03/26/2025, noted R9's BIMS (Brief Interview of Mental Status) of 15, which indicates R9 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor weights and meal intakes for a resident with significant weight loss for 1 (R45) of 5 residents reviewed for weight loss in the sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow enhanced barrier infection control precautions for two residents (R31, R42) of six residents reviewed for infection control in the sample of 28.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure sufficient staff were scheduled / available to provide timely care to meet the resident's needs. This failure has the potential to affect all 47 residents residing at the facility. Findings Include: 1. R5's admission Record documented R5 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus with diabetic chronic kidney disease, acute and chronic respiratory failure, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure, chronic kidney disease, stage 3, diverticulitis, and neuromuscular dysfunction of the bladder. R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to turn and reposition 2 (R5 and R9) of 3 residents reviewed for activities of daily living in the sample of 13. Findings Include: 1. R5's admission Record documented R5 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, type 2 diabetes mellitus with diabetic chronic kidney disease, acute and chronic respiratory failure, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, chronic diastolic congestive heart failure, chronic kidney disease, stage 3, diverticulitis, and neuromuscular dysfunction of the bladder. R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (R1) reviewed for medication administration in the sample of 5. Findings Include: R1's admission Record documented R1 was [AGE] years old, with an initial admission date to the facility of 11/23/2022. R1's admission Record documents the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD), type 2 diabetes mellitus, acute and chronic respiratory failure, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, stage 3 chronic kidney disease, chronic diastolic heart failure, benign lipomatous neoplasm of kidney, neuromuscular dysfunction of bladder, gout, and personal history of healed traumatic fracture. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow an independent smoker the right to choose when to smoke for 1 (R44) of 2 residents reviewed for smoking in a sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for 1 (R25) of 12 residents reviewed for advanced directives in the sample of 27. Findings Include: 1. R25's face sheet documented an admission date of [DATE], with diagnoses including: displaced avulsion fracture of tuberosity of right calcaneus, chronic obstructive pulmonary disease, hypertension, major depressive disorder, anxiety disorder, and unspecified glaucoma. R25's Illinois Department of Public Health (IDPH) Practitioner order for Life- Sustaining Treatment (POLST) Form documented a selection of Do Not Attempt Resuscitation/ DNR, with a signature of R25's Power of Attorney (POA) on [DATE], and a Physician signature on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure referral and coordination of PASARR (Preadmission Screening and Resident Review) Level II Screening was completed for 1 (R7) of 1 resident reviewed for PASARR assessments in the sample of 27. Findings Include: R7's admission Record documents a date of birth of [DATE], and an initial facility admission date of 1/29/21. This same document includes the following diagnoses: Other Schizophrenia with an onset date of 3/25/22, Major Depressive Disorder with an onset date of 11/17/20, and Generalized Anxiety Disorder, with an onset date of 12/17/12. R7's Notice of PASRR Level I Screen Outcome was dated 11/18/2020, prior to admission, and documented No Level II screening required. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was completed for a resident with a diagnosed mental disorder for 1 (R44) of 1 resident reviewed for PASARR Screening in the sample of 27. Findings Include: R44's admission Record documented an initial admission date to the facility of 2/13/2024. R44's diagnoses listed on this form include, but were not limited to: Bipolar Disorder, Unspecified and Major Depressive Disorder, Recurrent, Moderate. R44's Notice of PASRR Level I Screen Outcome, dated 2/13/2024, documented No Level II Required - No SMI (Serious Mental Illness) The PASRR Outcome Explanation Notice of No PASRR Level II Required report documents, Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure required bathing assistance was provided to dependent residents for 1 (R8) of 1 resident reviewed for ADL (Activities of Daily Living) care in the sample of 27. The Findings Include: R8's admission record documents an original admission date of 4/26/19, and a most recent re-admission date of 10/16/2023. R8's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Section GG of this same MDS documented R8 requires partial/moderate assistance with showers. (Partial/moderate assistance documents the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort). R8's current Care Plan documented a focus area of Self-Care Deficit As Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents medication regimens were free from unnecessary psychotropic medications for 1 (R7) of 5 residents reviewed for unnecessary medications in a sample of 27. The Findings Include: R7's admission record documents a date of birth of [DATE], and an initial facility admission date of 1/29/21. This same document includes the following diagnoses: Other Schizophrenia with an onset date of 3/25/22, major depressive disorder with an onset date of 11/17/20, and generalized anxiety disorder with an onset date of 12/17/12. R7's current physician order for the month of March 2024 included the following medication orders: Risperidone 1 milligram, give one tablet by mouth in the evening for schizophrenia with a start date of 9/2/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when prescribed medications were not available for 3 (R1, R5, R6) of 8 residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to acquire and administer medications for 3 (R1, R5, R6) of 8 residents reviewed for pharmacy services in a sample of 8.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse for 1 of 1 (R1) resident reviewed for abuse in the sample of 3. The Findings Include: On 9/12/23 at 9:30 AM, V1 (Administrator) stated she had an insurance representative come to her and report R1 reported she had been thrown into bed by V2 (Certified Nurse Assistant/CNA) and V3 (CNA). V1 stated she went down to R1's room and interviewed her regarding this report, and determined that it was not abuse. V1 confirmed at this time, she did not report this allegation of staff to resident physical abuse to the physician, family, police, or state agency and there are no notes in the medical record regarding this event. The facility's abuse policy, with a revision date of 4/18/23, documents , filing accurate and timely investigative reports. [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate alleged allegations of abuse for 1 of 1 resident (R1) reviewed for abuse investigations in a sample of 3. The Findings Include: On 9/12/23 at 9:30 AM, V1 (Administrator) stated she had an insurance representative come to her and report R1 reported she had been thrown into bed by V2 (Certified Nurse Assistant/CNA) and V3 (CNA). V1 stated she went down to R1's room and interviewed her regarding this report, and determined that it was not abuse. V1 further stated she spoke with V2 and V3 regarding the allegation of throwing R1 into her bed. V1 stated she questioned them both as to whether they used the patient transfer disc with R1 during the transfer from chair to bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label insulin pens with open dates for 4 of 7 residents (R9, R16, R30, and R31) reviewed for medication administration and storage in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow an independent smoker the right to choose when to smoke for 1 of 2 residents (R31) reviewed for smoking in a sample of 24 residents.

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge summary for 1 of 1 (R40) resident reviewed for discharge in a sample of 24. The Findings Include: R40's admission record documents an admission date of 2/17/23. R40's progress notes documents on 3/7/23 at 11:53 AM, he was being transported by ambulance home for discharge. On 4/21/23 at 11:00AM, V11 (Social Services) stated when a resident is discharged , there is a discharge summary that all departments are to fill out, regarding a summary of their stay here. V11 stated she cannot find where one of these forms was filled out for R40. On 4/21/23 at 11:30 AM, V1 (Administrator) stated she is unable to find a discharge summary at this time on R40.

Inspectors wroteBased on interview and record review, the facility failed to identify significant weight loss of a resident, and failed to notify the dietician and physician of the significant weight loss, for 1 of 2 residents (R11) reviewed for weight loss in the sample of 24. The Findings Include: R11's admission record documents a date of birth of [DATE], and an admission date of [DATE]. Diagnoses listed on this admission record include: Alzheimer's Disease and Dementia. R11's undated care plan does not document any focus area related to weight or intake. R11's Minimum Data Set (MDS), dated [DATE] section G, documents R11 requires supervision (oversight, encouragement or cueing) of one staff at meals. Section K of this same MDS documents under Weight Loss: Loss of 5% or more in the last month or loss of 10% or more is 6 months- Yes, not on a physician prescribed weight loss regimen. [...]