The Haven of Arcola: Resident-on-Resident Assault - IL
The incident at The Haven of Arcola is the subject of a federal complaint inspection completed November 18. Inspectors cited the facility for failing to protect residents from abuse, finding that the home had not done enough to prevent a foreseeable physical altercation between two residents whose care plans documented, in detail, why they should not have been left to navigate the same hallway without supervision.
The resident identified in the report as R2 is described as cognitively intact, oriented to person, place, time, and situation. Her care plan, dated as far back as February 2025, documents that she becomes anxious and agitated, has verbal outbursts, makes hateful and inappropriate comments, and is suspicious of others entering her room without permission. A separate care plan entry from September 2025 specifically flags her paranoia about people coming into her space.
The resident identified as R3 has dementia and paranoid schizophrenia. She has short and long-term memory impairment and is moderately impaired in her ability to make daily decisions. Her care plan, updated in July 2025, notes that she wanders the hallways, violates the personal space of others, does not comprehend social limits, and may be combative with staff.
The collision between these two women was not a mystery. It was a care plan waiting to happen.
On the afternoon of October 16, R3 came up behind R2 in the hallway. R3 grabbed the armrest of R2's wheelchair to propel herself forward, passing on R2's right side between the wall railing and the chair. A nursing assistant, identified in the report as V8, was coming out of the CNA room nearby and witnessed what followed.
R2 yelled at R3 and slapped her in the right hand three times. V8 described the strikes as intentional, saying R2 was "reprimanding R3 like you would a child." R3, according to V8, did not seem fazed or affected.
R2 told inspectors a different version. In an interview conducted the same day, R2 said R3 had smacked her on the hand first, so she smacked R3 back. R2 repeated this account to inspectors on November 17, adding that R3 gets into people's rooms and sleeps in their beds, and that the facility hadn't done much about it.
V8 told inspectors that R2 swears R3 hit her first, but that V8 did not see R3 strike R2. V8 said R3 may have accidentally bumped R2's hand when she grabbed the armrest. "R2 is with it, knows staff, and is alert and oriented," V8 said. "R3 is confused and in her own world."
When inspectors visited on November 17, R2 was in her room, sitting in her wheelchair. A mesh barrier had been stretched across the doorway, with a stop sign attached reading "Do Not Enter." R2 said the barrier was there because of R3's habit of wandering into rooms. R3, visited separately that morning, was sitting in a recliner in her own room. She responded to her name but did not respond to any questions.
The care plans for both women had been in place for months before the October altercation. R3's wandering behavior and inability to recognize social boundaries was documented in July. R2's paranoia about her personal space was documented in September, just three weeks before the incident. The facility knew who these two residents were, knew what each of them was prone to do, and knew what would happen when R3's wandering brought her into R2's space.
R3 did not seem fazed. That, perhaps, is the most unsettling detail in the report. She is confused, in her own world, and cannot comprehend what happened to her or why. She cannot tell anyone whether it hurt. She cannot ask for it not to happen again.
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.
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 21, 2026 · Our methodology
THE HAVEN OF ARCOLA in ARCOLA, IL was cited for violations during a health inspection on November 18, 2025.
The incident at The Haven of Arcola is the subject of a federal complaint inspection completed November 18.
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.