The October 16 assault happened when the dementia patient, identified as R3 in inspection records, grabbed onto another resident's wheelchair armrest while wandering the hallways. The other resident, R2, "got upset, yelled at R3 and slapped R3 in the right hand three times reprimanding R3 like you would a child," according to a nursing assistant who witnessed the incident.
Federal inspectors found the facility had specific care plan interventions designed to address R3's wandering behavior but failed to implement them. The patient's care plan called for "reorientation strategies including signs, pictures and memory boxes" to help her identify her room, but none were provided.
R3 has been diagnosed with dementia and paranoid schizophrenia. Her medical assessment documents show she has both short and long-term memory impairment and is "moderately impaired with cognitive skills for daily decision making." Her active care plan specifically identifies wandering as a problem, noting that she "wanders the hallways, into other resident rooms and gets into unoccupied beds."
The facility's own abuse prevention policy requires staff to identify residents with increased vulnerability and implement care plan approaches "which would reduce the chances of abuse, neglect, exploitation, mistreatment" for these residents.
But when inspectors visited R3's room on November 17, they found no pictures, memory boxes, or identifying signs anywhere in her room or near her doorway. Only a standard nameplate with her first initial and last name hung outside her door — the same type used for every resident in the facility.
Certified nursing assistant V14 confirmed that signs had been used on other residents' room doors to help them identify their rooms, "but this has not been done for R3."
The assault occurred around 2:20 PM when R3 was wheeling past R2 in a narrow space between a railing and R2's wheelchair. R2 "does not like people in R2's personal space," according to witness V8, and may have thought R3 had been in her room earlier.
V8 described the incident in detail: "As R3 wheeled passed on the right side of R2, between the railing and R2, R3 grabbed the arm rest of R2's wheelchair to propel herself. R2 got upset, yelled at R3 and slapped R3 in the right hand three times."
The nursing assistant immediately separated the two residents. R2 later claimed she was acting in retaliation, saying R3 had hit her first, but witnesses did not support that account.
V8 told inspectors that R3's wandering behavior had worsened after she experienced room changes over the past year. The nursing assistant acknowledged that R3 "does recognize things in her room, likes her jewelry and bedding" but confirmed that no pictures or signs had been implemented to help her identify her space.
When asked about using visual aids to help R3 recognize her room, V8 responded "that is a good idea, that might help R3 recognize R3's room."
The facility had documented R3's wandering problem in her care plan since October 2023, more than a year before the assault. The plan called for structured activities including toileting and walking, along with the reorientation strategies that were never implemented.
Staff told inspectors they try to redirect R3 when she wanders and have placed her on 15-minute visual checks. V14 noted that R3 "relaxes in R3's recliner and enjoys watching television" when she's in her own room.
But the basic environmental modifications that could have helped prevent the wandering behavior — and the subsequent assault — were simply not provided.
When inspectors observed R3 on November 17, she was sitting in her recliner and responded to her name but did not respond to questions. Her room remained devoid of the identifying features her care plan had specified for more than two years.
The incident was reported to the Illinois Department of Public Health as a serious injury on October 23, a week after it occurred. The state's incident report noted that R2 "open handed smacked R3 on R3's right upper arm" and that R2's claim of acting in self-defense was not supported by witness accounts.
The facility's failure represents exactly the kind of preventable incident its own policies were designed to avoid. The abuse prevention policy specifically requires staff to identify problems and approaches that would reduce chances of abuse for vulnerable residents like those with dementia.
R3's wandering into other residents' spaces created the conditions for conflict that staff should have anticipated and prevented through proper implementation of her care plan interventions.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it affected the facility's compliance with requirements to provide appropriate treatment and services to residents with dementia.
The inspection was conducted in response to a complaint, suggesting someone had raised concerns about care quality at the facility before the November visit.
R3 continues to live at The Haven of Arcola, still without the memory aids that might help her find her way back to her own room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Arcola from 2025-11-18 including all violations, facility responses, and corrective action plans.