The Haven Of Arcola

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to protect resident's right to privacy. This failure affected two of four residents (Resident R1, Resident R2) reviewed for resident rights on the sample list of four. Findings Include:The facility's Resident Rights Guideline policy dated October 2023 documents the practice of this facility is to provide an environment in which residents may exercise their rights, each day. Residents have certain rights and protections under Federal law and the facility will always protect these rights through care and related services. One example of a resident's rights is Privacy and Confidentiality. Resident R1's Medical Diagnoses List dated August 2025 documents Resident R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. Resident R1's Minimum Data Set, dated [DATE REDACTED] documents Resident R1 is cognitively intact. Resident R1's Behavior Tracking for July 2025 through August 2025 documents Resident R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Resident R1 entered other resident's rooms or personal space 17 times in the last 30 days. Resident R1's Care Plan dated 8/14/25 documents Resident R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Staff are to intervene as necessary to protect the rights and safety of others. Resident R2's Medical Diagnoses List dated August 2025 documents Resident R2 is diagnosed with Schizoaffective Disorder, Generalized Anxiety disorder, Depression, Insomnia, and Paranoid Personality Disorder. Resident R2's Care Plan dated 6/6/25 documents Resident R2 is cognitively impaired and has short term memory deficit. Resident R2 requires substantial/dependent assistance with activities of daily living. Resident R2 is incontinent and requires staff to provide perineal care at least every two hours. On 8/17/25 at 2:27 PM V9 Certified Nurses Assistant stated Resident R1 has a lot of anxiety and needs constant attention and reassurance. Resident R1 will follow staff into other resident's rooms and will not listen when you ask her not to do things. Resident R1 will invade other resident's privacy and is hard to redirect. R1will get into staff or resident's faces when asking them repetitive questions. V9 stated Resident R1 will often open the curtain to talk to staff while they are providing personal care for Resident R1's roommate (Resident R2). V9 stated staff will have to stop what they are doing to redirect Resident R1 and she continues to invade Resident R2's privacy. On 8/17/25 at 2:37 PM V7 Licensed Practical Nurse stated Resident R1 is constantly invading others' privacy and personal space. On 8/17/25 at 2:51 PM V6 Licensed Practical Nurse stated Resident R1 bothers other residents and invades their privacy. On 8/17/25 at 4:45 PM V2 Director of Nurses stated she was not aware of Resident R1 continually opening Resident R2's privacy curtain while staff are providing care and confirmed that is a violation of Resident R2's right to privacy.

Residents Affected - Few

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

08/17/2025

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 - Minimal harm or potential for actual harm Residents Affected - Few

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

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to protect resident's right to be free from verbal abuse. This failure affected two of four residents (Resident R1, Resident R3) reviewed for resident rights on the sample list of four. Findings Include:The facility's undated Abuse policy documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. Resident R1's Medical Diagnoses List dated August 2025 documents Resident R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. Resident R1's Minimum Data Set, dated [DATE REDACTED] documents Resident R1 is cognitively intact. Resident R1's Behavior Tracking for July 2025 through August 2025 documents Resident R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Resident R1's Care Plan dated 8/14/25 documents Resident R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia.

Staff are to intervene as necessary to protect the rights and safety of others. Resident R3's Medical Diagnoses List dated August 2025 documents Resident R3 is diagnosed with Bipolar Disease, Anxiety, and a Mild Cognitive Impairment. Resident R3's Minimum Data Set, dated [DATE REDACTED] documents Resident R3 is cognitively intact. Resident R3's Care Plan dated 2/11/25 documents Resident R3 exhibits behaviors caused by anxiousness with agitation which leads to verbal outbursts, mocking, yelling and demanding of others, sleep disturbances, refusal of care and false allegations. On 8/17/25 at 2:27 PM V9 Certified Nurses Assistant stated Resident R1 has a lot of anxiety and needs constant attention and reassurance. Resident R1 will follow staff into other resident's rooms and will not listen when you ask her not to do things. Resident R1 will invade other resident's privacy and is hard to redirect. R1will get into staff or resident's faces when asking them repetitive questions. V9 stated Resident R3 has verbally threatened Resident R1.

On 8/17/25 at 2:00 PM V5 Certified Nurses Assistant stated Resident R3 yelled at Resident R1 and stated Resident R1 should get the f*** (expletive) out of here or she will break Resident R1's hand. On 8/17/25 at 2:51 PM V9 Certified Nurses Assistant stated Resident R3 is always telling Resident R1 to shut up and go away. On 8/17/25 at 5:15 PM Resident R3 stated Resident R1 makes her very anxious and annoys her. Resident R3 stated Resident R1 follows staff around the entire shift. Resident R3 stated there are times where

she has gotten so annoyed with Resident R1, that she has threatened her. Resident R3 stated Resident R1's behavior causes her great anxiety. It is hard for her to be around Resident R1 and she is trying to be better. On 8/17/25 at 4:45 PM V1 Administrator confirmed that Resident R3, threatening Resident R1, could be considered verbal abuse. V1 also confirmed Resident R1's behaviors and repetitive questions put her at risk for abuse.

Event ID:

Facility ID:

If continuation sheet