Health inspection·March 19, 2024

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure therapy services were provided for five (R1, R2, R3, R4 and R5) of five residents reviewed for therapy services from a sample list of five residents. Residents Affected - Some Findings include: 1. On 3/19/24 at 2:21PM, R1 was laying in bed and stated, I received a couple of rounds of therapy in February and then they said that they weren't going to be returning to the facility. I had sat on the edge of the bed for the first time in months right before they quit coming. I was improving. Now, they don't get me out of bed at all except for showers. I want to do therapy and they said that there would be others coming to do therapy, but they haven't come. R1's physical therapy notes dated 2/18/24 document R1 was sitting on the side of the bed with therapy. R1's physician orders dated 2/9/24 document R1 to have speech, occupational and physical therapy services. R1's occupational and physical therapy notes dated 2/11/24-2/17/24 document R1 was receiving services 5 days per week. R1's occupational and physical therapy notes dated 2/18/24 document that the facility therapy company will no longer providing R1's therapy services as of 2/19/24. 2. On 3/19/24 at 2:15PM, R2 stated via writing on a communication board, I still want therapy because I want to walk. I'm waiting for someone to come. R2's physical therapy documentation dated 2/13/24 document R2 was walking with physical therapy. R2's therapy orders dated 2/12/24 document skilled speech therapy twice weekly for four weeks to target dysphasia and to decrease aspiration risk, physical therapy and occupational therapy three times a week. R2's therapy notes dated 2/18/24 document that the facility therapy company will no longer provide R2 with therapy services as of 2/19/24. 3. R3's therapy orders dated 1/23/24 document orders for occupational, speech and physical therapies three times a week for four weeks. R3's physical therapy notes dated 2/18/24 was walking with assist and transferring with assist and that the facility therapy provider would no longer be providing R3 with therapy services as of 2/19/24. On 3/19/24 at 10:00AM, V1 Administrator stated, R3's family wanted us to find alternative placement for R3 to have therapy, but we haven't been able to do so. He is a difficult placement because of behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145948 If continuation sheet Page 2 of 3 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 145948 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of Bement. 601 North Morgan Bement, IL 61813 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On 3/19/24 at 2:19PM, R4 was sitting in his recliner with his legs elevated and stated, They lost their contract for therapy, so I'm not getting any right now. I was working on upper body with (V7), but I can't do anything with this left leg.I will do therapy if they get another contract. R4's therapy orders dated 2/6/24 document orders for physical and occupational therapy three times a week. R4's physical and occupational therapy service notes end on 2/17/24. 5. R5's therapy orders dated 2/2/24 document physical, occupational and speech therapy three times a week for four weeks. R5's physical therapy notes dated 2/17/24 document that R5 demonstrated therapeutic exercises with good accuracy and used bilateral upper extremity weights for strength training. Additionally, the facility provided therapy company would no longer be providing services for R5 after 2/19/24. R5's progress notes dated 2/21/24 document that due to lack of therapy services, the family decided to take R5 home. On 3/19/24 at 10:00AM, V1 Administrator stated, When we called (R5's Power of Attorney) to tell them that we wouldn't have therapy for awhile, they just said that they wanted to take her home. On 3/19/24 at 9:30AM, V1 Administrator said that the facility had been without therapy services since 2/19/24 and that they were hoping to get a new company in soon. On 3/19/24 at 3:25PM, V1 Administrator said that the lack of therapy services was not good for the residents and that they could have declines in their progress due to the lack of services. On 3/19/24 there were no therapists working with residents, in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145948 If continuation sheet Page 3 of 3