The Haven of Arcola: Sexual Assault Ignored - IL
The Haven of Arcola's administrator later told federal inspectors she considered the July 29 incident "more of a resident rights issue than abuse" because the man didn't make contact with the woman's genitals.
The woman, identified in inspection records as R4, requires a wheelchair for mobility and needs supervision with basic activities including eating, toileting and bathing. Her medical conditions include depression, muscle wasting, and being unsteady on her feet. Federal inspectors found she is cognitively intact.
R4 wrote in her statement the day of the incident: "I was sitting next to the ping pong table. (R5) got up off the couch and came towards me. (R5) was standing and bent down and started rubbing my leg. (R5) started at the knee moving up towards my (points to vagina). I backed away from (R5) and went to my room. I don't know what (R5) was thinking."
Another resident witnessed the entire encounter. R6 told inspectors he watched R5 get up from the couch in the resident lounge and walk over to R4. R5 "put his hand on the inside of R4's lower thigh/knee area and squeezed lightly and then left his hand there for a few minutes."
Then R5 moved his hand "clear up there," R6 said, motioning to his genitals.
"I couldn't believe what I was seeing," R6 told inspectors. "I was in shock."
R6 watched R4 move her wheelchair back to get away from R5. He said R5 didn't make contact with R4's genitals, "but it wasn't for lack of trying."
Licensed Practical Nurse V7 spoke with R4 after the incident. R4 told the nurse that R5 "touched my leg and tried to reach my vagina. I didn't like that."
The nurse described the same sequence to inspectors: R5 walked up to R4, who was in her wheelchair, touched her upper thigh, then moved his hand toward her genital area before R4 wheeled herself away.
Staff sent R5 to the emergency room for evaluation after the incident.
Both residents live on the facility's locked psychiatric unit. Administrator V1 told inspectors that both R4 and R5 are cognitively intact but "unable to make decisions for themselves and require constant supervision."
The facility's own policy states that residents have the right to be treated with dignity and respect.
Federal inspectors found The Haven of Arcola failed to ensure resident dignity for R4 and two other residents during their August review. The violation was classified as causing minimal harm or potential for actual harm.
R4's care plan, initiated in November 2024, documents her medical diagnoses including thoracic scoliosis, depression, neuropathy, blood clots in her lower extremities, muscle wasting and major depressive disorder. Despite the July incident, her care plan contains no focus area, goal or interventions addressing what the facility described as R5's pattern of "consensual sexual behavior with male peers."
The inspection report notes that R5 had engaged in similar behavior with male residents before the July 29 incident involving R4.
The facility reported the incident to the state agency on August 1, two days after it occurred. The report documented R4's account that R5 started rubbing her upper leg then moved up to touch her perineal area while she sat in the dayroom. The report noted that R4 moved away and that R5 did not actually make contact with her genitals.
But the administrator's characterization of the incident as primarily a resident rights violation rather than potential abuse raises questions about the facility's response to protecting vulnerable residents.
R4 told staff she didn't like what happened and that she didn't know what R5 was thinking. The witness described R5's deliberate progression from touching R4's thigh to reaching toward her genitals, saying it appeared intentional.
The facility houses residents who require constant supervision on a locked psychiatric unit, yet failed to prevent an incident that left a wheelchair-bound woman feeling violated and unsafe.
Federal regulations require nursing homes to ensure residents can live with dignity and exercise their rights. The inspection found The Haven of Arcola violated these protections for multiple residents, including R4, who was unable to escape an unwanted sexual encounter while sitting in what should have been a safe common area.
The violation occurred despite facility policies stating residents have the right to dignified treatment. The disconnect between written policies and actual protection became evident when the administrator downplayed an incident that left a vulnerable resident retreating to her room after an unwanted sexual advance.
R4 remains a resident at the facility where the incident occurred. Her care plan still lacks interventions to address the behaviors that led to her being touched inappropriately in the dayroom while other residents watched.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Arcola from 2025-08-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE HAVEN OF ARCOLA in ARCOLA, IL was cited for violations during a health inspection on August 10, 2025.
Her medical conditions include depression, muscle wasting, and being unsteady on her feet.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.