The Haven Of Bement.
THE HAVEN OF BEMENT. in BEMENT, IL — inspection on October 10, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
fall.R3's Fall Risk assessment dated [DATE] classifies R3 as high fall risk.R3's Nurse Progress
attempted a self-transfer.7/4/25: The notes lack documentation about a fall at 9:29ˆPM.8/8/25 at
omit details of a fall at 1:40ˆAM.R3's Fall Investigations:7/2/25: An unwitnessed fall at 4:30ˆAM occurred when R3 was trying to get up and was incontinent.
The investigation does not include a rootˆcause analysis.7/4/25: An unwitnessed fall at 9:29ˆPM found R3 lying next to his bed and incontinent. No rootˆcause is provided.8/8/25: An unwitnessed fall at 4:15ˆAM left R3 on the floor beside his bed; he said he attempted to self-transfer. No root cause is documented.9/23/25: An unwitnessed fall at 1:40ˆAM found R3 on the floor beside his bed and incontinent.
The investigation notes that R1 was unable to describe the fall. No root cause is identified.On 10/10/25 at 9:35ˆAM, V11 CNA transferred R3 from his bed to his wheelchair without additional staff, without a mechanical lift, and without a gait belt.At 9:40ˆAM, R3 was in his wheelchair in the dining room drinking hot coffee. No staff were present.
His wheelchair seat was not lowered, and no personal alarms were installed.At 10:00ˆAM, V11 CNA admitted she transferred R3 without help, without the lift, and without a gait belt.
She said she knew two staff and a mechanical lift were required but sometimes does not follow that.
She said staff practices vary-sometimes using the lift, sometimes physically transferring R3.At 10:15ˆAM, V7, Director of Rehabilitation Services, assessed R3's wheelchair.
She observed the seat was in its highest position, though it could be lowered.
She said wheelchair adjustments are normally reviewed with therapy.
She was unaware that R3's Care Plan includes lowering the seat.At 11:25ˆAM, V1 Administrator stated that R3's fall interventions did not align with his falls on 7/2/25, 7/4/25, 8/8/25, and 9/23/25, particularly because no root causes were documented.
The Administrator said that when a resident falls, the interdisciplinary team (IDT) should discuss the fall, implement an appropriate intervention plan, and educate staff.
She said merely documenting what happened is insufficient to identify a root cause.
She commented: Just because (R3) tries to get up on his own does not tell us why he is attempting to get up.
The root cause might be incontinence, hunger, pain, etcetera.She concluded that the root causes of R3's falls were never determined.The facility policy titled Falls Guideline, revised August 2024, defines a fall as any failure to maintain appropriate lying, sitting, or standing position that results in unintentional relocation to the ground or another object lower than the starting point. It mandates that all residents at fall risk be reviewed for individualized interventions.
Fall management should include review of physical devices, hazard analysis, cause identification, intervention development and implementation, and ongoing evaluation.
Staff must evaluate and document all falls-including when and where they occurred and observational details.
Documentation should contain sufficient information to help determine the cause of the fall.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.