The Haven Of Arcola

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to ensure resident dignity for three of three residents (Resident R4, Resident R5, Resident R6) reviewed for dignity in a sample list of seven residents.Resident R4's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R4 as cognitively intact. This same MDS documents Resident R4 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene and bed mobility. Resident R4's Care plan documents medical diagnoses as Thoracic Scoliosis, Depression, Neuropathy, Thrombophlebitis of Lower Extremities, Unsteady on Feet, Muscle Wasting and Atrophy and Major Depressive disorder. This same care plan initiated 11/8/24 does not document a focus area, goal nor interventions for Resident R4's behaviors of consensual sexual behavior with male peers prior to 7/29/25. This same care plan documents Resident R4 requires a wheelchair for mobility. Resident R5's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R5 as cognitively intact. Resident R6's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R6 as cognitively intact. Resident R4 and Resident R5's shared Final Report to the State Agency dated 8/1/25 documents Resident R4 stated Resident R5 started rubbing her upper leg then moved up to touch her perineal area while she was sitting in the day room. This same report documents Resident R4 moved away from Resident R5 and that Resident R5 did not actually touch Resident R4's perineal area. Resident R4's written statement dated 7/29/25 documents (Resident R4) was sitting next to the ping pong table. (Resident R5) got up off the couch and came towards me. (Resident R5) was standing and bent down and started rubbing my leg. (Resident R5) started at the knee moving up towards my (points to vagina). I backed away from (Resident R5) and went to my room. I don't know what (Resident R5) was thinking. On 8/9/25 at 12:10 PM V7 Licensed Practical Nurse (LPN) stated Resident R5 touched Resident R4 inappropriately in the hall next to the dayroom on the South unit on 7/29/25. V7 LPN stated Resident R5 walked up to Resident R4 who requires a wheelchair and touched Resident R4's upper thigh and then moved his hand farther towards Resident R4's genital area then Resident R4 wheeled herself back away from Resident R5. V7 LPN stated Resident R4 told V7 that ‘(Resident R5) touched my leg and tried to reach my vagina. I didn't like that.' V7 LPN stated Resident R5 was sent to the emergency room for evaluation due to his behaviors. On 8/9/25 at 2:55 PM Resident R6 stated Resident R4 was sitting in the resident lounge in her wheelchair when Resident R5 got up off of the couch (in the same room) and walked over to Resident R4. Resident R6 stated Resident R5 put his hand on the inside of Resident R4's lower thigh/knee area and squeezed lightly and then left his hand there for a few minutes. Resident R6 stated Resident R5 then moved his hand ‘clear up there' (Resident R6 motioned to his perineal area). Resident R6 stated he couldn't believe what he was seeing. Resident R6 stated he was in shock. Resident R6 stated he saw Resident R4 move her wheelchair back away from Resident R5. Resident R6 stated he did not think Resident R5 made contact with Resident R4's perineal area but that ‘it wasn't for lack of trying.'

On 8/10/25 at 10:00 AM V1 Administrator stated Resident R4 and Resident R5 both reside on a locked psychiatric unit. V1 Administrator stated both Resident R4 and Resident R5 are cognitively intact yet unable to make decisions for themselves and require constant supervision. V1 Administrator stated she thinks this incident is more of a resident rights issue than abuse due to Resident R5 did not make contact with Resident R4's perineal area. The facility policy titled Resident Rights Guideline revised October 2023 documents residents have the right to be treated with dignity and respect.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Arcola

422 East Fourth Street Arcola, IL 61910

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on 7/22/25 to identify opportunities for improvement/deficient practice. 2. Immediate action consisted of: Resident R1 and Resident R2 were immediately separated. Resident R1 was sent to the emergency room for evaluation and returned on continual monitoring (1:1) supervision. This continual monitoring was in place until Resident R1 could be seen by psychiatry at which time, Resident R1 was placed on 15 minute visual checks which have remained in place. 3.

Actions completed and/or ongoing by 7/25/25: All staff were in serviced on behavioral intervention resources prior to the next shift; All behavioral care plans were reviewed to ensure interventions were in place; All Gradual Dose Reduction (GDR) requests and increases in behaviors within the last three months were reviewed; Behavioral Tracking and GDR audits were scheduled for three times the first week, twice the second week and then weekly for four weeks and were initiated and ongoing and; Resident care plans will be audited weekly for four weeks to ensure timely behavioral interventions are appropriate and effective with behavior tracking in place. Staff in-service on ‘Different ways to deescalate behaviors and put interventions in place' was completed on 7/25/25. Care plans and GDRs were reviewed by V1 Administrator, V2 DON and V16 Regional Clinical Nurse. Behavioral care plans and GDR audits were initiated on 7/22/25 and completed on 7/25/25. 4. V1 Administrator will report the findings to the QAPI meeting quarterly. V1 Administrator stated the facility has not had the next QAPI meeting but thus far there have been no new substantiated instances of abuse since 7/18/25.

Event ID:

Facility ID:

If continuation sheet