Fair Havens Senior Living
FAIR HAVENS SENIOR LIVING in DECATUR, IL — inspection on August 13, 2025.
Found 4 citations. 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
the nurse on duty on 7/12/25 and sometime in the afternoon a CNA reported to her that when providing cares to R2 and when the CNA removed the brief there was a washcloth in the brief. V8 stated that 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 R2 returned from dialysis R2 requested help in getting cleaned up due to having a smell from his body. V11 stated 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 R2 was very upset at the smell and that a washcloth was left inside the brief. V11 stated R2 requested to be left alone once cares were completed. On 08/04/2025 at 2:30 PM, Employee handbook dated revised [DATE], 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fair Havens Senior Living
1790 South Fairview Avenue Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
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 (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.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 R2 has moderate cognitive impairment.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: 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.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 R11 is cognitively intact.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, R2 stated that he received a new roommate (R11) on 8/8/25, with whom R2 stated he did not get along with.
R2 stated R11 wanted the room dark, curtains pulled and R11 turned up the television really loud. R2 stated R11 began cussing R2 so R2 began yelling and threatened to beat up R11 with bodily injury.On 8/11/25 at 10:45am, R11 stated his belongings were moved to room [ROOM NUMBER] without his knowledge on 8/8/25 and that R2 had yelled at R11 and R2 threatened R11 with bodily injury.On 8/13/25 at 11:43am, V32, housekeeper, stated she was at the nurse's station and heard R2 and R11 yelling at each other and heard R2 threaten R11 with bodily harm. V32 stated staff went to room [ROOM NUMBER] and moved R11 back across the hall to room [ROOM NUMBER]. V32 stated R11 has had multiple residents and is hard to get along with.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fair Havens Senior Living
1790 South Fairview Avenue Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
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 (R7) of one resident reviewed for blood glucose monitoring in a sample list of nine residents.
These failures resulted in R7 being hospitalized for Diabetic Ketoacidosis.Findings include:On [DATE] at 2:00 pm, R7's care plan dated [DATE] documents an admission date of [DATE] with the diagnosis of Heart Failure and Type 2 Diabetes Mellitus with Hyperglycemia. R7 admitted to the facility for therapy with the discharge plan to return home.R7's Discharge Plan dated [DATE] 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] at 2:00pm, 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] at 0900.On [DATE] at 2:00pm, R7
Record review does not contain a physician order for blood glucose monitoring- check blood sugar before meals and at bedtime. On [DATE] at 2:22pm, R7
Record review of nursing progress notes documents on [DATE] at 06:17am, V21 LPN (Licensed Practical Nurse) documents R7 exhibited symptoms of altered mental status with a blood glucose over 500mg/dl (milligrams per deciliter). On [DATE] at 2:22pm, the next progress note entered in the R7's Record review of nursing progress notes documents V22 LPN, called the local hospital in regard to the condition of R7 and was told R7 was admitted to the hospital with Diabetic Ketoacidosis and Urinary Tract Infection. On [DATE] at 2:25pm, hospital record review documents R7 arrived at the local hospital emergency room on [DATE] at 6:31am.On [DATE] 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 R7 blood glucose was over 600.
Laboratory results obtained in the hospital document a blood sugar of 738mg/dl.On [DATE] at 10:27am, V16 Primary Care Physician stated R7's elevated blood glucose level on [DATE] at 06:00am was secondary to infection and likely would have been elevated at bedtime. On [DATE] at 1:25pm, V21 LPN stated on the morning of [DATE] at 06:00am, V21 went into R7's room to do the blood glucose and 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 R7 to the emergency room.
V21 stated R7's blood glucose readings were elevated at times.On [DATE] at 10:22am, V3 DON and V4 ADON, confirm R7's transfer physician orders dated [DATE] document Blood Glucose monitoring - check blood sugar before meals and at bedtime. V3 DON and V4 ADON confirm 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Fair Havens Senior Living
1790 South Fairview Avenue Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 (R1, R2, 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. R1's Clinical Census, undated, documents an original admission date of 4/14/22.
Minimum Data Set completed on [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates R1 is cognitively intact.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 R2 has moderate cognitive impairment. 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 R3 is cognitively intact. On 7/24/25 at 10:00am, R1 stated the food always arrives cold. R1 stated R1 has told staff about the cold food before. On 7/24/25 at 10:05am, R3 stated the food is delivered cold and often tasteless. R3 stated that R3 has asked staff to warm her food in a microwave to warm it up.On 7/24/25 at 10:15am, R2 stated the food is not very good or warm and R2 often eats out especially on dialysis days. On 7/24/25 at 12:22pm, R1 stated the lunch food on R1's plate is cold.On 7/24/25 at 12:25pm, R3 stated the food was cold. On 8/4/25 at 12:30pm, R1 stated the lunch was cold and bland. On 8/4/25 at 12:33pm, R3 stated R3's lunch plate was cold. On 8/4/25 at 12:35pm, 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.
Facility ID: