F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to administer a dietary supplement according to
physician's orders for one resident (R3) of one resident reviewed for following physician's orders in the
sample list of three.
Residents Affected - Few
Findings include:
R3's undated Cumulative Diagnosis Log, documents R3's diagnosis as: Transischemic Attack (TIA) and
Cerebral Infarction.
R3's Physician Order Sheet (POS) dated 7/1/24 to 7/31/24, documents Med Pass 2.0 Supplement 60
milliliters (ML) by mouth twice a day.
R3's Medication Administration Record (MAR) dated 7/1/24 through 7/31/24, documents Med Pass 2.0
Supplement as not given to R3 on the following dates: 7/7/24, AM and PM; 7/11/24 AM and PM; 7/16/24
PM; and 7/19/24 AM.
On 7/18/24 at 3:06 PM, V2 Director of Nursing (DON), verified on previous dates, R3 did not receive Med
Pass Supplement.
R3's Care Plan dated 3/22/24, documents to provide and serve supplements as ordered.
The facility's Conformance with Physician Medication Orders dated Reviewed 9/27/17, documents all
medication, headache remedies, vitamins, etcetera shall be given upon written order of a physician.
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:
146017
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
146017
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Haven of Champaign
1315 Curt Drive, Suite B
Champaign, IL 61821
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 0801
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to employ a clinically qualified Director of Food
and Nutrition. This failure has the potential to affect all 47 residents residing in the facility.
Findings include:
On 7/18/24 at 10:40 AM, V1 Administrator stated they do not have a Dietary Manager at this time, V1 stated
the facility had a Dietary Manager for five days but that person abandoned the job so we let him go. V1
stated V1 has been working in the kitchen a lot and comes in every weekend and at other times to cook. V1
stated V2 Director of Nursing (DON) has also been helping to cook.
On 7/18/24 at 12:30 PM, V2 DON stated V2 has been cooking for the past one and a half to two weeks.
Throughout this survey, from 7/18/24 through 7/19/24, a Dietary Manager was not present in the facility.
The facility's Food Service Manager job summary dated 10/16, documents qualifications for this position
include: must have taken or be willing to take the Dietary Managers Course and have passed the sanitation
test or be willing to take the course approved by the state the facility is in.
The facility's room roster dated 7/18/24, documents 47 residents reside in the facility.
The Facility assessment dated [DATE], documents a Dietician or other clinically qualified nutrition
professional to serve as the director of food and nutrition services 8 hours per day.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146017
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
146017
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Haven of Champaign
1315 Curt Drive, Suite B
Champaign, IL 61821
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 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition
service.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to have qualified dietary aides and a cook. This
failure has the potential to affect all 47 residents who reside in the facility.
Findings include:
The Facility assessment dated [DATE], documents food and nutrition services staff be in the facility 14
hours per day.
The facility's Diet Aide job summary dated 10/16, documents a dietary aide must have passed the
sanitation test or be willing to take the course approved by the state the facility is in and must receive food
handler's training within 30 days of employment.
On 7/18/24 at 12:30 PM, V2 Director of Nursing (DON) stated V2 has been cooking at the facility for one
and a half to two weeks.
On 7/18/24 at 3:30 PM, V1 Administrator stated V4, the cook, does not have a cooking/sanitation
certificate, also V5 and V6 diet aides do not have a food handlers certificate at this time. At this same time,
V1 stated V1 was not aware that V4 needed a cooking/sanitation certificate.
On 7/18/24 at 3:45 PM, V2 DON stated V2 does not have a certificate to be cooking.
On 7/19/24 at 8:30 AM, V4, cook, stated V4 does not have a cooking/sanitation certificate and just found
out today (7/19/24) that V4 needed it.
The facility's Room Roster dated 7/18/24, documents 47 residents reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146017
If continuation sheet
Page 3 of 3
