Fair Havens Senior Living: Call Light Failures - IL
The inspection that documented this took place on May 28 and 29, 2026, at Fair Havens Senior Living, a nursing facility at 1790 South Fairview Avenue in Decatur. The complaint inspection focused on whether residents had working means to call for help. Of five residents reviewed, one was found to be without access to her call light repeatedly, across two consecutive days.
That resident, identified in inspection records only as R2, was admitted to the facility in July 2025. Her care plan lists a history of falling, anxiety disorder, cognitive impairment, and dementia. A formal assessment documents moderate cognitive impairment. Her fall risk was not theoretical. The facility's own incident log shows she fell on April 25, May 8, May 12, and May 17, 2026, four falls in 23 days in the weeks before the inspection.
Her care plan, written at admission, was explicit: ensure the call light is within reach and encourage her to use it for assistance as needed. R2 needs prompt response to all requests for assistance.
On the morning of May 28, a surveyor found R2 sitting in her wheelchair in the middle of her room. The call light was on the floor next to her bed. She was approximately seven feet away from it.
That was at 9:37 a.m.
At 10:00 a.m., the call light was still on the floor in the same spot. R2 was still in her wheelchair, still out of reach of it.
At 11:47 a.m., two hours and ten minutes after the first observation, the call light had not moved. R2 told the surveyor she did not know where the call light was.
At 12:15 p.m., a certified nursing assistant came into R2's room. The surveyor asked where the call light should be placed. The aide said call lights should be where residents can see them, closer so residents do not need to move a lot to reach them. The aide confirmed the call light was on the floor. The aide said it should not be on the floor.
Then the aide left without picking it up.
Three minutes later, a registered nurse came in. The nurse said the call light should be next to the resident where she can reach it. The nurse confirmed it was on the floor. The nurse said it should not be on the floor because R2 cannot reach it. The nurse said she would move it.
That was four hours and forty-one minutes after the first observation.
The next morning, May 29, at 7:40 a.m., the call light had been moved. It was now clipped to the privacy curtain, about four feet off the floor and approximately five feet from R2, who was lying in bed.
A different certified nursing assistant came in at 7:45 a.m. and confirmed the call light was clipped to the curtain. The aide said it should be next to R2, not clipped to the curtain.
The Director of Nursing, interviewed at 12:09 p.m. on May 29, said she expects call lights to be within residents' reach.
The facility's own call light policy, dated January 1, 2025, states that staff will follow established procedures to respond to residents' requests and needs, and that the call light must be within easy reach of the resident. Every staff member the surveyor spoke with knew this. Each one confirmed the situation was wrong. None of them, until the nurse on the afternoon of May 28, did anything about it.
What makes this finding hard to dismiss as a paperwork deficiency is the specific combination of factors documented in R2's record. She has dementia. She told the surveyor she did not know where her call light was, which is consistent with her diagnosis and also consistent with what inspectors observed: it had been on the floor, out of her line of sight and well beyond her reach, for the better part of a morning. She had fallen four times in the previous month. Her care plan identified falls as an active risk and named call light access as one of the primary interventions to reduce that risk.
A resident with moderate cognitive impairment cannot be expected to problem-solve around a call light that has fallen to the floor and gone unnoticed by the staff responsible for placing it. She cannot get up from a wheelchair to retrieve it without the very assistance the call light is meant to summon. The logic is circular and the gap it creates is exactly the kind that precedes a fall.
CMS rated the harm level as minimal harm or potential for actual harm, the lower end of the agency's scale. The deficiency did not rise to immediate jeopardy. The facility was cited under the regulatory category governing residents' rights, specifically the right to receive the services and accommodations necessary to meet their needs.
The inspection covered six residents total. R2 was the only one found to be without access to a call light. That narrowness is not reassurance. It means that on two consecutive mornings, during a formal complaint inspection, with surveyors present and observing, the same resident sat in her room unable to call for help, and the staff who noticed said the right things and kept walking.
R2's care plan goal, written when she was admitted ten months ago, is that she will be free of falls through the next review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fair Havens Senior Living from 2026-05-29 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 19, 2026 · Our methodology
FAIR HAVENS SENIOR LIVING in DECATUR, IL was cited for violations during a health inspection on May 29, 2026.
The complaint inspection focused on whether residents had working means to call for help.
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.