Fair Havens Senior Living

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the nurse on duty on 7/12/25 and sometime in the afternoon a CNA reported to her that when providing cares to Resident R2 and when the CNA removed the brief there was a washcloth in the brief. V8 stated that Resident R2 was very mad and upset and refused an assessment of the area and wanted to be left alone. On 07/24/25 at 1:48pm, V11 CNA stated when Resident R2 returned from dialysis Resident R2 requested help in getting cleaned up due to having a smell from his body. V11 stated Resident R2 was transferred to the bed via the total mechanical body lift, rolled over and removed the brief and discovered a wet washcloth in the skin fold between the gluteus maximus (butt cheeks). V11 stated Resident R2 was very upset at the smell and that a washcloth was left inside the brief. V11 stated Resident R2 requested to be left alone once cares were completed. On 08/04/2025 at 2:30 PM, Employee handbook dated revised [DATE REDACTED], documents on page 3: We count on you, our employees, to focus on the provision of quality care and excellent services for our residents and to do so with a high level of dignity, compassion, and responsiveness to their physical, medical, and emotional needs. Our residents deserve nothing less than your best each and every day.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fair Havens Senior Living

1790 South Fairview Avenue Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to protect one resident (Resident R11) from verbal abuse for one of three residents reviewed for verbal abuse on a sample list of nine.Findings Include: Facility Abuse Prevention Program policy effective 10/2022, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services.

This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an Individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. The policy documents as part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents.

Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.Resident R2's Clinical Census, undated, documents an original admission date of 8/31/23. Minimum Data Set completed

on July 23, 2025, documents a Brief Interview for Mental Status (BIMS) score of 12 of 15. A score of 12 indicates Resident R2 has moderate cognitive impairment.Resident R2's Care plan dated 09/01/2023 documents diagnosis of: End Stage Renal Disease, Essential (Primary) Hypertension, Hereditary and Idiopathic Neuropathy, Paraplegia. The same care plan documents: Usual ADL (Activities of Daily Living) Performance: Resident R2 is independent for eating with set up help. Max A (maximum assistance) of one to two is needed for personal hygiene, dressing, toileting & bed mobility, and is dependent with transfers with a total body mechanical lift of two.Resident R11's Clinical Census, undated, documents an original admission date of 5/8/2025. Minimum Data Set completed on May 14, 2025, documents a Brief Interview for Mental Status (BIMS) score of 15 of 15. A score of 15 indicates Resident R11 is cognitively intact.Resident R11's Care plan dated 05/21/2025 documents diagnosis of Alcohol Abuse, Calculus of Gallbladder without Cholecystitis without Obstruction, Hypertensive Heart Disease without Heart Failure, Hypothyroidism, Gastro-Esophageal Reflux Disease without Esophagitis, Hyperlipidemia, Peripheral Vascular Disease, Essential (primary) Hypertension, Pain in Right Wrist, Osteoarthritis, Alcohol Dependence with Alcohol-Induced Persisting Dementia.On 8/11/25 at 10:30am, Resident R2 stated that he received a new roommate (Resident R11) on 8/8/25, with whom Resident R2 stated he did not get along with. Resident R2 stated Resident R11 wanted the room dark, curtains pulled and Resident R11 turned up the television really loud. Resident R2 stated Resident R11 began cussing Resident R2 so Resident R2 began yelling and threatened to beat up Resident R11 with bodily injury.On 8/11/25 at 10:45am, Resident R11 stated his belongings were moved to room [ROOM NUMBER] without his knowledge on 8/8/25 and that Resident R2 had yelled at Resident R11 and Resident R2 threatened Resident R11 with bodily injury.On 8/13/25 at 11:43am, V32, housekeeper, stated she was at the nurse's station and heard Resident R2 and Resident R11 yelling at each other and heard Resident R2 threaten Resident R11 with bodily harm. V32 stated staff went to room [ROOM NUMBER] and moved Resident R11 back across the hall to room [ROOM NUMBER]. V32 stated Resident R11 has had multiple residents and is hard to get along with.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fair Havens Senior Living

1790 South Fairview Avenue Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Practical Nurse V28 stated the expectation is that the CNA will inform the nurse when a resident is having loose stools, and the nurse will inform the physician. V28 stated that the nurses have access to bowel and bladder charting and can look to see how the residents are being charted on. V28 confirms the documentation of loose/diarrhea stools in the medical record of Resident R7. V28 confirmed V22 should have called

the physician on the telephone after completing the SBAR. V28 confirms there is no SBAR (Situation, Background, Assessment, and Recommendation form) completed by V22 in the medical record. Example 3Based on interview and record review, the facility failed to ensure physician orders were accurately transcribed and implemented for one (Resident R7) of one resident reviewed for blood glucose monitoring in a sample list of nine residents. These failures resulted in Resident R7 being hospitalized for Diabetic Ketoacidosis.Findings include:On [DATE REDACTED] at 2:00 pm, Resident R7's care plan dated [DATE REDACTED] documents an admission date of [DATE REDACTED] with the diagnosis of Heart Failure and Type 2 Diabetes Mellitus with Hyperglycemia. Resident R7 admitted to the facility for therapy with the discharge plan to return home.Resident R7's Discharge Plan dated [DATE REDACTED] at 8:59:32 documents on page three (3) under section Discharge Instructions: * Blood Glucose monitoring check blood sugar before meals and at bedtime. On [DATE REDACTED] at 2:00pm, Resident R7 Record review documents a physician order for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) -Start Date [DATE REDACTED] at 0900.On [DATE REDACTED] at 2:00pm, Resident R7 Record review does not contain a physician order for blood glucose monitoring- check blood sugar before meals and at bedtime. On [DATE REDACTED] at 2:22pm, Resident R7 Record review of nursing progress notes documents on [DATE REDACTED] at 06:17am, V21 LPN (Licensed Practical Nurse) documents Resident R7 exhibited symptoms of altered mental status with a blood glucose over 500mg/dl (milligrams per deciliter). On [DATE REDACTED] at 2:22pm, the next progress note entered in the Resident R7's Record

review of nursing progress notes documents V22 LPN, called the local hospital in regard to the condition of Resident R7 and was told Resident R7 was admitted to the hospital with Diabetic Ketoacidosis and Urinary Tract Infection. On [DATE REDACTED] at 2:25pm, hospital record review documents Resident R7 arrived at the local hospital emergency room on [DATE REDACTED] at 6:31am.On [DATE REDACTED] at 2:25pm, Record review of hospital notes V23 Registered Nurse (RN), documents Nursing home reports altered mental status. That patient was sweating and clammy with a temp of 102.4 and Resident R7 blood glucose was over 600. Laboratory results obtained in the hospital document a blood sugar of 738mg/dl.On [DATE REDACTED] at 10:27am, V16 Primary Care Physician stated Resident R7's elevated blood glucose level on [DATE REDACTED] at 06:00am was secondary to infection and likely would have been elevated at bedtime. On [DATE REDACTED] at 1:25pm, V21 LPN stated on the morning of [DATE REDACTED] at 06:00am, V21 went into Resident R7's room to do

the blood glucose and Resident R7 was not acting herself. V21 stated she proceeded to do the blood glucose, and it did not register on the meter, it stated high. V21 stated V21 proceeded to send Resident R7 to the emergency room.

V21 stated Resident R7's blood glucose readings were elevated at times.On [DATE REDACTED] at 10:22am, V3 DON and V4 ADON, confirm Resident R7's transfer physician orders dated [DATE REDACTED] document Blood Glucose monitoring - check blood sugar before meals and at bedtime. V3 DON and V4 ADON confirm Resident R7's medical record physician orders section does not contain the physician order for Blood Glucose monitoring - check blood sugar

before meals and at bedtime.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fair Havens Senior Living

1790 South Fairview Avenue Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to ensure hot food was served to for three residents (Resident R1, Resident R2, Resident R3) out of three reviewed for dietary services in a sample list of nine.Random observations were completed

on 7/24/25 through 8/4/25 related to dietary services, during observations the hall tray cart was delivered to

the hallway and nursing staff would deliver trays to the residents. The trays contained the afternoon meal on

a plate with a cover. No hot plate under the ceramic plate to keep the food warm. The trays also contained cold food and the drinks. On 7/24/25 at 12:00 PM, the lunch food cart was delivered to the 300 hall by kitchen employee, nursing staff did not pass the trays for 12 minutes to residents. On 8/4/25 at 12:07pm the lunch cart was delivered to the 300 hall, nursing staff passed the meals from the cart at 12:18pm. Resident R1's Clinical Census, undated, documents an original admission date of 4/14/22. Minimum Data Set completed

on [DATE REDACTED], documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates Resident R1 is cognitively intact.Resident R2's Clinical Census, undated, documents an original admission date of 8/31/23.

Minimum Data Set completed on July 23, 2025, documents a Brief Interview for Mental Status (BIMS) score of 12 of 15. A score of 12 indicates Resident R2 has moderate cognitive impairment. Resident R3's Clinical Census, undated, documents an original admission date of 1/21/25. Minimum Data Set completed on July 1, 2025, documents a Brief Interview for Mental Status (BIMS) score of 14. A score of 14 indicates Resident R3 is cognitively intact. On 7/24/25 at 10:00am, Resident R1 stated the food always arrives cold. Resident R1 stated Resident R1 has told staff about the cold food before. On 7/24/25 at 10:05am, Resident R3 stated the food is delivered cold and often tasteless. Resident R3 stated that Resident R3 has asked staff to warm her food in a microwave to warm it up.On 7/24/25 at 10:15am, Resident R2 stated

the food is not very good or warm and Resident R2 often eats out especially on dialysis days. On 7/24/25 at 12:22pm, Resident R1 stated the lunch food on Resident R1's plate is cold.On 7/24/25 at 12:25pm, Resident R3 stated the food was cold. On 8/4/25 at 12:30pm, Resident R1 stated the lunch was cold and bland. On 8/4/25 at 12:33pm, Resident R3 stated Resident R3's lunch plate was cold. On 8/4/25 at 12:35pm, Resident R2 stated he did not eat the lunch because it was cold and didn't taste good. On 8/5/25 record review of Resident Council minutes dated 4/24/25 documents the residents stated the food is cold. Resident Council minutes dated 5/26/25 document the residents stated

the food is cold.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet