Inspection·June 23, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to change an indwelling urinary catheter per physician's orders for 1 of 3 residents (R1) reviewed for urinary catheters in a sample of 16. Findings include: R1's admission Record documents an admission date of 11/23/22, with diagnoses including chronic kidney disease, benign lipomatous neoplasm of kidney, and neuromuscular dysfunction of the bladder. R1's Minimum Data Set, dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section H, Bladder and Bowel, documents R1 was indwelling urinary catheter. R1's Care Plan documents a Focus area with an initiation date of 6/8/23 of: High Risk for Urinary Tract Infection due to: Indwelling Catheter. Documented interventions include Change catheter and drainage bag per MD orders with an initiation date of 6/8/23. R1's Order Summary Report, with a print date of 6/17/25, documents an order of, Catheter: 18 FR (french) Coude catheter with 10cc (cubic centimeter) balloon Dx (diagnosis) Neuromuscular Dysfunction of Bladder; change once monthly and PRN (as needed) one time a day every 28 day(s) for infection prevention, with an order date of 6/16/25. R1's Treatment Administration Record (TAR) for April, May, and June 2025 documents an order, dated 3/28/25, to change catheter once monthly and PRN. There is no documentation on the April, May, and June 2025 TAR's indicating R1's catheter was changed. R1's Progress Note's in the Electronic Health Record (EHR), dated 3/28/25, documents, Nurse received N.O. (new order) to insert an 18 Fr 10ml (milliliter) coude catheter d/t (due to) res. (resident) catheter coming out c (with) balloon intact. Nurse inserted c no resistance felt and no c/o (complaints of) pain or discomfort at this time. Catheter patent and drng (draining). There was no documentation in R1's EHR documenting R1's catheter was changed since 3/28/25. On 6/16/25 at 10:47 AM, R1 stated she had not had her indwelling urinary catheter changed since 3/28/25. On 6/17/25 at 10:55 AM, V13 (Medical Doctor/MD) stated his expectations for the facility would be to change R1's indwelling urinary catheter as ordered. V13 stated that means he would expect the (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 6 Event ID: 146119 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 146119 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven on the River 320 South 2nd Street Grayville, IL 62844 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)