Health inspection·October 9, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for accidents in a sample of 5. This failure resulted in R1 falling from the lifting machine, hitting her head and receiving three staples to repair a 1.2 cm (centimeter) laceration to the back of her scalp.This past non-compliance occurred between 9/14/2025 and 9/15/25.Findings included:R1's admission Record documented R1 was admitted to this facility on 2/25/2025, with diagnoses of type 2 diabetes mellitus, essential hypertension, opioid dependency, chronic pain and spinal stenosis among others.R1's MDS (Minimum Data Set) assessment, dated 8/4/2025, documented R1 with a BIMS (Brief interview for Mental Status) score of 12 out of 15, which indicated R1 is cognitively intact. This same MDS under section GG (Functional Ability) documented R1 has impairment to both lower extremities and is dependent on staff for all transfers and toileting.On 9/29/2025 at 10:00am, R1 said on 9/14/2025 right after lunch, she needed to use the commode and put her call light on. R1 said the staff use a lifting machine that lifts her to a standing position and then will lower her onto the commode and back to her chair again. R1 said V4 (Certified Nursing Assistant/CNA) answered her call light. R1 said, by himself, V4 placed the lifting straps around her and tightened them, but when V4 used the lifting machine to lift her up, she slipped out of the straps and fell to the floor, hit her head and caused a laceration. R1 said she was sent to the local emergency room and received 3 staples in her scalp to close the laceration.On 9/29/2025 at 2:00pm, V4 said he was the staff providing care for R1 on 9/14/2025. V4 said about 1:00pm, he answered R1's call light, and R1 said she needed to use the bedside commode. V4 said he knows two staff are to be present when using the patient lift machines, but this time he did not wait for more staff to come and transferred R1 by himself and used the lift machine. V4 said he strapped R1 into the lifting machine and began to lift her up. V4 said during mid transfer, R1 slipped out of the straps and fell backwards. V4 said he tried to grab R1 but could not. V4 said when R1 fell from the lifting machine, she hit her head and caused a laceration.R1's emergency room records, dated 9/14/2025, documented the following in part: (R1) states the staff was getting her up to go to the bathroom using a stand assist device when (R1) passed out and fell off. (R1) has a small 1.2cm laceration to the right posterior scalp where 3 staples were used to repair the wound.The facility's Final Report and Conclusion of Incident form under the section titled Summary of Investigative findings is documented: A comprehensive investigation was completed and found on September 14, 2025. (R1) was noted to have sustained a witnessed fall in her room attempting to use sit to stand lift with CNA (Certified Nursing Assistant). Upon initial assessment the resident was noted to have a laceration to her scalp. POA (Power of Attorney) and MD (Medical Doctor) were notified with an order obtained to send to ER (Emergency Room) for eval (evaluation) and treat. (R1) returned to facility with three staples for closer [SIC] of laceration. The facility has completed a root cause analysis and concluded that the root cause was improper use of (mechanical lifting device).On 9/29/25 at 9:00am, V1 (Administrator) said it was 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 2 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 10/09/2025 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)