The Haven of Bement: Fall Safety Failures for High-Risk Resident - IL
That was the morning of October 10, when state inspectors were present.
The resident, identified in inspection records as R3, had already fallen four times since July. On July 2, he was found on the floor beside his bed at 4:30 in the morning, incontinent, having tried to get up on his own. On July 4, the same scene: beside his bed, on the floor, incontinent, 9:29 at night. August 8, again beside his bed at 4:15 in the morning. September 23, on the floor at 1:40 in the morning, incontinent again, unable to describe what had happened.
Not one of the four investigations identified a root cause.
When inspectors spoke with the nursing assistant that morning, she acknowledged she knew the transfer required two staff members and a mechanical lift. She said she sometimes skips those requirements anyway, and that practices vary among staff.
The Director of Rehabilitation Services, called in to assess R3's wheelchair at 10:15 that morning, found the seat at its highest position. She said wheelchair adjustments are normally reviewed with therapy. She had not known that R3's care plan required the seat to be lowered.
The facility's own administrator told inspectors the fall investigations were inadequate. She said documenting that a resident tried to get up on his own is not a root cause. "Just because he tries to get up on his own does not tell us why he is attempting to get up," she said. "The root cause might be incontinence, hunger, pain, etcetera."
She concluded that the root causes of R3's falls were never determined.
Between July and October, R3 fell four times in the dark, alone, beside his bed. Nobody found out why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Bement. from 2025-10-10 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
THE HAVEN OF BEMENT. in BEMENT, IL was cited for violations during a health inspection on October 10, 2025.
That was the morning of October 10, when state inspectors were present.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.