Health inspection·June 27, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to protect the residents right to be free from physical abuse by another resident for two residents (R1, R2) of three reviewed for abuse in the sample of three. Findings include: The facility Abuse Prevention Program policy (2/2021) documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The same record documents Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. R2's diagnosis list (6/27/2024) documents diagnoses including: Quadriplegia (paralysis of legs and arms), Epilepsy (seizure disorder), Cortical Blindness (visual blindness associated with brain damage), Profound Intellectual Disabilities, Cerebral Palsy, and Major Depressive Disorder. R2's Resident Assessment (6/6/2024) documents R2 has severely impaired cognition, is completely dependent on staff assistance to perform all activities of daily living, uses a wheelchair, and has left and right side upper extremity impairment. R1's Resident Assessment (5/20/2024) documents R1 does not have any upper extremity impairment. R1's Care Plan (6/27/2024) documents R1 is physically aggressive including grabbing others, biting, and pinching. The same record documents an entry on 5/20/2024 with the goal that R1 will not harm R1's self or other people. The facility Resident Abuse incident investigation (6/16/2024) documents R1 and R2 were seated beside each other in the facility dining room on 6/16/2024 when R2 began making noises that agitated R1 and R1 proceeded to slap R2 on the thigh approximately 10 times. On 6/27/2024 at 1:50PM, V2 (Unit Aide) reported being present in the facility dining room on 6/16/2024 when the altercation between R1 and R2 occurred. V2 reported hearing R2 scream but a different type of scream than her usual sound, more of an ow I'm hurt high pitch scream. V2 reported turning around in the dining room after initially hearing R1 slap R2 and hearing R2's screams and then observed R1 slapping R2 on R2's right thigh repeatedly. V2 reported R1 slapped R2 additionally at least five or six times after V2 turned around to observe the altercation between R1 and R2. (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 3 Event ID: 145948 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 06/27/2024 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)