The resident, identified as R1 in inspection records, exited the building through the southwest door at 5:10 AM on November 10. Staff found him in the field at 6:15 AM. Emergency medical services transported him to the local hospital, where doctors diagnosed hypothermia.
On November 12 at 5:15 PM, the facility's administrator and social service designee served R1 with involuntary discharge papers while he remained hospitalized for his exposure injuries.
Federal inspectors found the facility violated regulations by failing to provide required 30-day advance notice for the involuntary discharge.
R1 has schizoaffective disorder and drug-induced movement problems, according to physician orders from November. His most recent mental status assessment scored 15 out of 15, indicating he was cognitively intact.
The facility's administrator told inspectors on November 15: "Yes R1 was delivered involuntary discharge papers because we are not a locked unit and R1 needs locked doors to keep him from exiting on his own." The administrator said the facility would take R1 back "if they would adjust his medication so R1 would not want to leave the building."
The facility lacks locked exit doors, which allowed R1 to leave through the southwest entrance.
R1's half-brother, who had maintained phone contact with him at the facility, told inspectors: "R1 can barely talk he has a speech problem. I asked him what happened and he won't tell me anything."
Hospital staff described R1 as abandoned by the discharge decision. The Director of Care Services at the local hospital said on November 18: "The facility served R1 papers for an involuntary discharge and he has no one to advocate for him. We did a new psychological evaluation and the results were R1 is alert and oriented, decision making skills are there also but R1 would not be able to live alone."
The hospital director continued: "R1 would not be able to take care of himself, we are asking his brother to help assist us with placement elsewhere. No progress for this goal so far. R1 is his own person but he can not take care of himself."
The facility had been R1's home for more than two decades. The hospital's care director noted: "The facility R1 was at is the only place R1 has been in the last 20 some years."
An ombudsman organization intervened to help with the discharge process and planned to file for a hearing to challenge the involuntary removal.
A nurse practitioner who works with mental health clients at The Haven told inspectors she agreed with the hospital's psychological assessment of R1.
The facility's policy from September 2016 states transfers and discharges should be "conducted in accordance with residents' rights" and "maintain continuity of care for the resident."
Federal regulations require nursing homes to provide 30 days' written notice before involuntarily discharging a resident, except in emergency situations. The regulation is designed to give residents and families time to find alternative placements and appeal discharge decisions.
R1 remains hospitalized with no secured placement, according to the November 18 inspection records.
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.