Health inspection·July 29, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm 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 two (R1 and R2) of three residents from verbal and mental abuse from a total sample of three residents reviewed for abuse. Residents Affected - Few Findings include: The facility provided Abuse Prevention Program Policy dated 11/28/2016 documents that the facility affirms the right of its' residents to be free from abuse or mistreatment including protecting residents from verbal abuse from staff. Verbal abuse is identified in the policy as 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 their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of harm, or saying things to frighten a resident. Mental abuse includes threats of punishment or deprivation. On 7/29/24 at 9:00AM, R1 was sitting at the table in the dining room. R1 did not respond to verbal communication. R1's 7/14/23 cognitive assessment documents R1 as severely cognitively impaired. R2's 6/13/24 cognitive assessment documents R2 as cognitively intact. On 7/25/24 at 1:30PM, V1 Administrator said that R1 has a lot of behaviors in the dining room, rolling up to the counter and getting into things. On 7/25/24 at 2:00PM, V5 Certified Nursing Assistant (CNA) said that she witnessed the incident between R1 and V4 [NAME] on July 13, 2024. V5 CNA said that the dietary department was short on the night in question. When I came into the dining room, (V4 Cook) was yelling at (R1) and at me saying that if you don't do something with him, I'm leaving. V4 [NAME] then told R1 that he wasn't going to feed anyone if he didn't go back and sit at his table and that (R1) was definitely eating last. I then saw (R1) reach for something on the counter and V4 [NAME] raised his hand to hit R1. I quickly moved R1 away so that there could be no contact. It was shocking to me and he made R1 wait until last to eat. On 7/25/24 at 2:30PM, R2 said that she remembered seeing V4 [NAME] yell at R1 a few weeks ago and that it was very upsetting. R2 said that she told V3 Resident Care Coordinator about it that night. R2 said that V4 was yelling at R1 for messing things up on the counter before supper and that she saw V4 [NAME] raise his hand to hit R1, but V5 Certified Nursing Assistant (CNA) moved R1 before V4 could hit him. (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 7 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 07/29/2024 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)