The Haven of Bement.

In the surveyor’s words

From the most serious findings on record at The Haven of Bement., in the surveyor’s own words.

• Actual harm, isolatedF600Mar 13, 2026

  Based on observation, interview, and record review the facility failed to protect the residents' right to be free from verbal and physical abuse by another resident for two of four residents (R18, R23) reviewed for abuse on the sample list of 27. This failure resulted in R23 experiencing physical pain, distress, and fear after R44 hit R23 in the stomach on three separate occasions. 1. R23's Census Detail and Medical Diagnoses List dated 3/10/26 documents R23 was admitted to the facility 11/3/25 with medical diagnoses including Cerebral Vascular Accident with Physical Symptoms, Quadriplegia, Anxiety, and Contractures. […]

• Actual harm, isolatedF602Jan 21, 2026

  Based on Interview and record review the facility failed to replace misappropriated goods in a reasonable time frame for one (R3) of three residents reviewed for misappropriation. R3 was upset and angered of having to replace (ear buds) with R3's own personal money and the facility not reporting this to the police as R3 wanted to press charges. This failure to report to the police and to replace the goods in a timely fashion resulted in psychosocial harm to R3.Findings Include:The Facilities Abuse Prevention Policy Dated 1/25 documents that the facility affirms the right of the resident to be free from misappropriation of property, deprivation of goods and services by staff or mistreatment. […]

• Actual harm, isolatedF692Jan 21, 2026

  Based on interview and record review the facility failed to accurately assess a resident for weight loss for one (R1) of three residents reviewed for nutrition. A significant weight loss was not identified, and interventions were not put in place to prevent further weight loss resulting in R1 being admitted to the hospital with a diagnosis of Hypokalemia due to malnutrition/dehydration.Findings include:The facility policy Lab, Diagnostic Test Results and Change in Resident's Condition - Clinical Protocol Dated November 2016 documents to establish guidelines for physician notifications concerning resident lab and diagnostic tests results and change(s) in resident conditions. The policy further documents 2. […]

• Actual harm, isolatedF689Oct 10, 2025

  Based on observation, interview and record review the facility failed to maintain transport equipment in working order and failed to safely secure one resident (R1) by not applying a seatbelt properly during resident transport. R1 experienced pain and obtained two nasal fractures and six sutures after falling while being transported in the facility van. The facility failed to implement fall interventions and failed to determine root causes for four falls for one (R3) resident. These failures affected two (R1, R3) residents out of three residents reviewed for Accidents in a sample list of three residents.Findings include: 1. […]

• Actual harm, isolatedF690Dec 12, 2024

  Based on interview and record review the facility failed to monitor urine characteristics, timely report changes in urine and urine culture results to the provider, and implement infection control measures to prevent catheter associated urinary tract infections (CAUTI) for one (R32) of two residents reviewed for UTIs in the sample list of 30. These failures resulted in delayed treatment of R32's CAUTI and hospitalization . Findings include: The facility's Notification for Change in Resident Condition or Status policy dated 12/7/17 documents to notify the resident's physician for sudden, change or unrelieved symptoms, when there is a need to alter treatment significantly and when there are symptoms of infection. […]