F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to notify the physician of a resident's physical change of
condition. This failure affects one of three residents (R1) reviewed for nursing care in the sample of three.
Findings Include:
The facility's Notification for Change in Resident Condition or Status dated 12/7/17 documents the facility
staff shall promptly notify appropriate individuals (medical provider) of changes in the resident's
medical/mental condition and/or status.
R1's Medical Diagnoses list dated September 2024 documents R1 is diagnosed with Dementia, Covid-19,
Heart Failure, Dissociative and Conversion Disorder, Major Depression, and Lewy Body Dementia.
R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired.
R1's Medication Administration Record dated August 2024 documents R1's Risperdal (Antipsychotic) was
increased on the afternoon of 8/22/24 from 0.5 milligrams two times per day to 2 milligrams two times per
day due to uncontrollable behaviors and risk to others. The new increased dose was given to R1 on the
evening of 8/22/24, the evening of 8/23/24, and two times each day on 8/24/24 and 8/25/24.
R1's Progress Note dated 8/26/24 documents on the morning of 8/26/24, R1 was observed to be lethargic,
sleeping
more than usual, was not able to stay awake to eat, and appeared sedated since the increase in dose of
Risperdal.
R1's Progress Note dated 8/27/24 documents R1 continued with her change of condition status and was
still lethargic, sleepy, and not eating or drinking. R1 was sent to the hospital for evaluation. R1 returned to
the facility later that day after receiving intravenous fluids.
On 9/7/24, V5 Registered Nurse stated he was the nurse that took care of R1 over the weekend of 8/24/24
and 8/25/24. V5 stated he knew R1's Risperdal had increased pretty significantly in the last couple days
and did notice the entire weekend, R1 was lethargic, would not get out of bed, would not eat or drink, and
had stopped talking. V5 stated he did not notify any medical providers regarding R1's change of condition.
V5 confirmed he should have notified V3 Nurse Practitioner of R1's physical changes.
(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 2
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
09/09/2024
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 9/7/24 at 1:08 PM, V8 Certified Nurses Assistant stated on 8/24/24 and 8/25/24, R1 was not her normal
self. V8 stated R1 was not able to get out of bed, eat or drink, and would not talk. V8 stated she was
concerned for R1 and reported the changes to V5 Registered Nurse but it didn't seem like anything was
done.
On 9/9/24, V3 Nurse Practitioner stated the facility nursing staff need to vigilantly assess residents who
have recently had a psychotropic medication change. V3 stated she was not notified until 8/26/24 of R1's
changes in physical condition at which point she decreased the Risperdal and then eventually sent R1 to
the Emergency Room. V3 confirmed she should have been notified on 8/24/24 when R1 became lethargic
and stopped eating, talking, or getting out of bed.
Event ID:
Facility ID:
145948
If continuation sheet
Page 2 of 2
