Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to administer prescribed medications at the prescribed time.
This failure has the potential to affect all 49 residents residing in the facility. Findings include:1. R3's Face
Sheet documents an admission date of 11/23/22, with diagnoses including chronic kidney disease, chronic
obstructive pulmonary disease, chronic venous hypertension, chronic congestive heart failure, and type 2
diabetes mellitus.R3's Minimum Data Set (MDS), dated [DATE] in section C, documents R3 has a Brief
Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. Section N of same MDS
documents R3 is ordered the following classes of medications: diuretic, opioid, antiplatelet, and
hypoglycemic (insulin).R3's Care Plan, dated 7/17/25, documents a focus area that R3 is on diuretic
therapy related to edema. Interventions for this focus area include administering diuretic medications as
ordered by physician with an initiation date of 4/10/23. Another focus area documents that R3 has a mood
problem. Documented interventions for this focus area include administer medication as ordered with an
initiation date of 1/6/23.R3's July 2025 Medication Administration Records (MAR) documents R3 has
medications scheduled to be administered at the following times: 7:00 AM, 8:00 AM, 12:00 PM, 4:00 PM,
5:00 PM, and 8:00 PM. R3's MAR provided did not document the actual time the medication was
administered.A Resident Grievance form filed by R3, dated 6/19/25, states R3 voiced concerns with
timeliness of medication pass at night.On 8/13/25 at 9:54 AM, R3 stated she frequently doesn't get her 8:00
PM medications until midnight. R3 stated in one instance, she did not get her scheduled 8:00 AM
medications until 2:00 PM in the afternoon. 2. R4's Face Sheet documents an admission date 2/25/25, with
diagnoses including, but are not limited to, depression, hypertension, hypothyroidism, and
osteoarthritis.R4's MDS, dated [DATE], documents in section C that R4 has a BIMS score of 13, indicating
R4 is cognitively intact. Section N of same MDS documents R4 is on the current class of medications:
antidepressant, diuretic, opioid, antiplatelet, and hypoglycemic.R4's Care Plan, dated 8/4/25, documents a
focus area of R4 takes a psychotropic medication. A related intervention to the previous focus area includes
administering medications as indicated by physician orders, with an initiation date of 8/1/25. Another focus
area documents R4 has hypertension. A related intervention is to give antihypertensive medications as
ordered, with an initiation date of 5/22/25. Another focus area on the R4's Care Plan documents R4 has
diabetes mellitus. A related intervention for this focus area is to administer diabetes medication as ordered
by doctor, with an initiation date of 5/22/25. Another focus area listed on R4's CP is she has chronic pain
related to other chronic pain, osteoarthritis, carpal tunnel syndrome and depression. A related intervention
includes to administer analgesia as per orders, with an initiation date of 2/25/25.R4's July 2025 Medication
Administration Records (MAR) documents R4 has medications scheduled to be administered at the
following times: 5:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 5:00 PM, and 8:00 PM. R4's MAR provided did not
document the actual time the medication was administered.On 8/13/25 at 9:37
(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 4
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
08/19/2025
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
AM, R4 stated she often doesn't get her scheduled 8:00 PM medications until 10:30 PM or 11:00 PM. R4
stated one time she didn't get her 8:00 PM medications until 12:30 AM.On 8/18/25 at 11:34 AM, V7,
Licensed Practical Nurse (LPN) stated she is often over the ordered time range of two hours for medication
administration, by up to one and a half hours. V7 gave the example of the 8:00 PM medication pass should
be completed by 9:00 PM, but she is frequently not finished until 10:30 PM. V7 stated the 8:00 PM
medication pass is a large one, and it needs two nurses to get it completed in the ordered time range.On
8/18/25 at 3:20 PM, upon this surveyor asking for July MAR's for R3 and R4 with documented and
timestamped medication administration times from V2, Director of Nursing/DON, he stated he was
instructed by his superior, V24, Chief Operating Officer, not to turn the time stamped MAR's over to this
surveyor because the facility had started an internal Quality Assurance investigation, and those documents
were now considered confidential. V2 stated he had been instructed by his superior to not allow this
surveyor to even visualize the time stamped MAR's in the Electronic Health Record on V2's computer. V2
stated the internal investigation was started approximately 2-3 weeks ago. V2 stated the internal
investigation was started when R3 and R4 had brought it to administration's attention that medications were
being administered past the ordered time ranges. V2 stated he has had complaints from floor nurses the
medication passes are too large to be completed in the ordered time range of two hours. V2 stated
presently, at times, R3 and R4 are continuing to complain medications are being administered past the
ordered time range.On 8/13/25 at 1:47 PM, V8, Certified Nurse's Aide (CNA), stated R3 has specifically
mentioned to him she had not gotten her medications on time specifically when V4, Registered Nurse (RN),
was working.On 8/13/25 at 2:14 PM, V11, CNA, stated she has had complaints from residents about
getting their medications late, past the ordered time range, but she was unable to recall any names.On
8/13/25 at 2:32 PM, V13, CNA, stated she has had multiple residents complain that they did not get their
medications administered at the correct time. V13 stated in the past, she also has had R3 and R4 complain
about their medications being administered late past the ordered time range. V13 also stated she had
residents complain to her (couldn't remember who) V4, RN, had left for two hours one evening when she
was supposed to have been administering medications.On 8/14/25 at 8:15 AM, V14, CNA, stated she has
had multiple complaints from residents about not getting their medications administered at the ordered time
frame especially when V4, RN, was working. The residents who mentioned this to her were specifically
complaining they were not getting their 5:00 PM or 8:00 PM medications at all.V4, RN, no longer works at
the facility and was unable to be reached for an interview.On 8/14/25 at 10:01 AM, V15, CNA, stated she
had many residents complain to her they were not getting their medications until past the ordered time
range, especially on the midnight shift from 6:00 PM-6:00 AM.On 8/14/25 at 12:44 PM, V2, Director of
Nurses (DON), stated there are some nurses, especially on midnight shift, struggling to get medications
administered within the ordered time range. On 8/14/25 at 3:00 PM, V23, RN, stated on occasion, she is
1-2 hours out of the ordered time range for administering the medications ordered to the residents.On
8/14/25 at 3:31 PM, V21, RN, stated when she worked the floor, she would be past the ordered time range
to administer medications one out of every three shifts on average every week. V21 stated she was up to
30 minutes to one hour past the ordered time range.On 8/18/25 at 10:01 AM, V17, RN, stated she
frequently goes over the ordered time range for medication administration by approximately thirty
minutes.On 8/18/25 at 10:26 AM, V5, RN, stated she is usually 10-15 minutes up to thirty minutes over the
ordered time range for administering medications.The Resident Council meeting minutes, dated 7/17/25 at
2:00 PM, documents residents voiced concerns about not being administered their pain medications on
time.The facility's Medication Administration Policy, with a revised date of 9/17/22, states,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146119
If continuation sheet
Page 2 of 4
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
08/19/2025
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Medications will be administered safely to residents within the facility by licensed nurses at the specified
time/timeframe.The facility's Daily Census sheet, dated 8/13/25, documents there are 49 residents residing
in the facility.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146119
If continuation sheet
Page 3 of 4
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
08/19/2025
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on interview and record review, the facility failed to provide medical records requested to aide in the
survey process for 2 of 2 residents (R3 and R4) reviewed for medication administration in a sample of
19.Findings includeOn 8/14/25, this surveyor reviewed the July 2025 Medication Administration Records
(MAR's) for R3 and R4 in their Electronic Health Records. The MAR's for R3 and R4 did not document the
actual time the medication was administered.On 8/14/25 at 3:30 PM, this surveyor requested R3 and R4's
July 2025 MAR's with documented and timestamped medication administration times from V2, Director of
Nurses (DON).On 8/18/25 at 8:00 AM, V2, DON, stated he had been instructed by V24, Chief Operating
Officer, not to provide the copies of R3 and R4's MAR's with documentation of the times the medications
were administered or allow this surveyor to visualize them in the Electronic Health Record.On 8/18/25 at
3:20 PM, V2, DON, he stated he was instructed by V24 not to turn the time stamped MAR's R3 and R4 over
to this surveyor because the facility had started an internal Quality Assurance investigation, and those
documents were now considered confidential. V2 stated the internal investigation was started
approximately 2-3 weeks ago. V2 stated the internal investigation was started when R3 and R4 had brought
it to administration's attention that medications were being administered past the ordered time ranges.
Event ID:
Facility ID:
146119
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the August 19, 2025 survey of The Haven on the River?
This was a inspection survey of The Haven on the River on August 19, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at The Haven on the River on August 19, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.