Health inspection·December 28, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a resident from staff verbal abuse for one of three residents (R1) reviewed for abuse in the sample of 36. These failures resulted in R1 feeling intimidated and verbally abused by V4 (RN/Registered Nurse) and R1 experiencing ongoing mental anguish, fear, and anxiety. Findings include: The facility's Abuse Prevention Program policy dated October 2022 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by establishing and environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. 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. R1's admission Record documents R1 was admitted to the facility on [DATE] with the diagnosis of Paraplegia. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact and has no behaviors. On 12-27-24 at 10:00 AM R1 was sitting up in his bed. R1's eyebrows were raised and R1's eyes were wide open when he stated in a high-pitched, shaky voice, Last Tuesday (12-17-24) around 7:30 PM I was in my room and had just sprayed room spray. The room stunk. I told (V5/CNA/Certified Nursing Assistant) to close the door so the stink from the hallway did not come into my room. V4 (Registered Nurse) was out in the hallway and came storming into my room like the Tasmanian Devil, got in my face, and yelled at me, 'Let me school you on when you can and cannot call the state in here. You do not get to tell us when the state can come in here.' (V4) looked like she wanted to fight me. I told (V4) that I said the stink not the state. I am paralyzed and cannot defend myself. (V4) scared me and I yelled at (V4) to get the f*** out of my room. (V5) was in the room and witnessed (V4) yelling at me. (V5) told me she could not believe that (V4) yelled at me like that and felt like (V4) wanted to Whip my a**! My heart rate was up and I have had so much anxiety over this since (V4) did this. I text (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145422 Printed: 05/15/2026 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2024 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)