Haven of Champaign: Neuro Check Failures After Head Injury - IL
Federal inspectors cited the facility following a complaint inspection on April 29, 2026.
The incident unfolded during a morning shower. A certified nursing assistant identified in the report as V15 had the resident standing in the shower stall, holding a rail, while trying to put a depend on her after washing her. The resident, who inspectors noted is cognitively impaired and doesn't enjoy showers, started to slip. V15 caught her under the arms and got her back into the shower chair.
V15 told inspectors she was hurrying because the resident was confused and resistant. She said she never saw the resident hit her head.
A second aide, V18, had helped transfer the resident into the shower chair at the start and then left, promising to return in 15 minutes. When V18 came back to help move the resident from the shower chair to her wheelchair, V15 mentioned the resident had slipped a bit but said nothing about a head injury. It wasn't until both aides had the resident back in her room and were combing her hair that they noticed dried blood on her scalp.
That detail matters. The blood was already dry. Whatever happened in that shower room, enough time had passed for bleeding to stop and crust over before anyone knew it had happened at all.
The nurse on duty, a licensed practical nurse identified as V12, saw the wound once the resident was back in her room. She sent the resident to the hospital immediately. The hospital summary, dated February 26, documents a laceration to the head and two staples placed to close it. The facility's own investigation report, filed the following day, described the resident as having had behavioral episodes during the shower, bumping her head on the shower room wall, and receiving two sutures.
So by February 27, the facility knew: head injury, laceration, staples, hospital visit, same-day return.
The neurological assessment policy Haven of Champaign has carried since August 2008 is specific. After a head injury, staff are required to check the resident every 15 minutes for four hours, then every hour for four hours, then every two hours for four hours, then every two hours for eight hours, then every four hours until a full 72-hour period is complete — unless a physician orders otherwise. The schedule exists because head injuries in elderly, cognitively impaired residents can produce delayed symptoms: confusion that looks like baseline dementia, pressure that builds slowly, changes that don't announce themselves.
None of those checks happened.
When inspectors spoke with the facility's assistant director of nursing, identified as V2, she confirmed it directly. Neurological checks were not done, she said, because the resident had gone to the hospital. She acknowledged the checks should have been completed after the resident returned to the facility that same day.
The resident returned the same day. The policy was not optional. Nobody did the checks.
What makes this harder to dismiss is the uncertainty at the center of the incident. Two aides were present at various points. Neither witnessed the impact. V15 said she didn't see the resident hit her head. V18 said V15 mentioned a slip but said nothing about a head injury. The facility's investigation report concluded the resident bumped her head on the shower wall during a behavioral episode. The nursing assessment written at the time says the CNA reported the resident hit the back of her head.
Nobody actually saw it happen. The resident, cognitively impaired, could not say what occurred.
That uncertainty is precisely what neurological monitoring is designed to catch. A resident who cannot reliably report dizziness, nausea, or worsening confusion after a head injury depends entirely on staff checking in, watching, comparing what they see now to what the baseline looked like an hour ago. For 72 hours after that shower, nobody was doing that math.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven of Champaign from 2026-04-29 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 7, 2026 · Our methodology
Haven of Champaign in CHAMPAIGN, IL was cited for violations during a health inspection on April 29, 2026.
Federal inspectors cited the facility following a complaint inspection on April 29, 2026.
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.