The Haven of Bement: Fall Safety Failures Harm Resident - IL
The resident, identified in inspection records only as R3, had already fallen four times between July and September of this year. Every fall happened in the early morning hours. Every fall was unwitnessed. Every fall left him on the floor beside his bed, incontinent. Not one investigation identified why he kept getting up alone.
R3's diagnoses include reduced mobility, muscle wasting and atrophy, muscle weakness, a cognitive-communication deficit, and mild neurocognitive disorder. His most recent assessment classified him as moderately cognitively impaired and dependent on staff for transfers, toileting, bathing, dressing, and personal hygiene. His care plan has required a total-body mechanical lift with two staff for every transfer since June 2020.
After a fall in August 2024, staff added two more interventions: lower his wheelchair seat, and install a personal alarm on the wheelchair. Neither was in place on the morning inspectors visited.
At 9:35 a.m. on October 10, a CNA identified as V11 moved R3 from his bed to his wheelchair alone. Twenty-five minutes later, R3 was in the dining room drinking hot coffee. No staff were present. His wheelchair seat was in its highest position. No alarm had been installed.
At 10 a.m., V11 acknowledged what she had done. She told inspectors she knew the transfer required two people and a mechanical lift. She said she sometimes does not follow that. She described the practice among staff as inconsistent — sometimes using the lift, sometimes not.
The facility's Director of Rehabilitation Services, identified as V7, examined R3's wheelchair at 10:15 a.m. She confirmed the seat could be lowered. She said wheelchair adjustments are normally reviewed with therapy. She did not know R3's care plan required the seat to be lowered.
The four falls that preceded that morning each went uninvestigated in any meaningful way. On July 2, R3 was found sitting on the floor at 4:30 a.m., incontinent, after attempting to get up on his own. The investigation recorded what happened. It did not examine why. On July 4, he was found lying next to his bed at 9:29 p.m., incontinent again. No root cause. On August 8, he was on the floor at 4:15 a.m., beside his bed, and told staff he had tried to transfer himself. No root cause. On September 23, he was found on the floor at 1:40 a.m., incontinent, and could not describe what had happened. No root cause.
The facility's own administrator, identified as V1, said at 11:25 a.m. on the day of the inspection that none of the four fall investigations had identified a root cause, and that none of R3's fall interventions had been updated in response to any of the falls. She said the interdisciplinary team should have convened after each incident, examined the circumstances, and developed a response. Documenting that a fall occurred, she said, is not the same as understanding it.
"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 had never been determined.
The facility's own Falls Guideline policy, revised in August 2024, requires that fall management include cause identification, hazard analysis, intervention development, and ongoing evaluation. It requires documentation sufficient to help determine why a fall occurred. None of R3's four investigations met that standard, by the administrator's own account.
Inspectors cited the facility for actual harm under federal deficiency tag F0689, which addresses accident hazards and supervision. The level of harm was classified as actual harm affecting a few residents.
What the record does not contain is any explanation for why a resident who cannot safely transfer himself, who has fallen four times in three months, who requires a mechanical lift and two staff members for every move, was left alone in a dining room with a cup of hot coffee and a wheelchair seat set at its highest position, with no alarm, while the staff member who put him there admitted she knew the rules and chose not to follow them.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
THE HAVEN OF BEMENT. in BEMENT, IL was cited for violations during a health inspection on October 10, 2025.
The resident, identified in inspection records only as R3, had already fallen four times between July and September of this year.
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.