The Haven Of Arcola

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

V8 Certified Nursing Assistant's (CNA) written Witness Statement dated 10/16/25 documents V8 was coming out of the CNA room and Resident R3 grabbed onto the armrest of Resident R2's wheelchair and Resident R2 started smacking Resident R3's arm. V8 immediately separated Resident R2 and Resident R3.

The typed interview with Resident R2 dated 10/16/25 documents the incident occurred on Resident R2's hallway a little past Resident R2's doorway. The interview documents Resident R2 saw Resident R3 coming down the hallway and as they passed each other Resident R3 smacked Resident R2 on the hand, so Resident R2 smacked Resident R3 back. Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R2 as cognitively intact. Resident R2's active Care Plan documents a problem dated 9/26/25 Resident R2 that Resident R2 is suspicious and paranoid of others entering her room without permission. This care plan includes a problem dated 2/11/25 that Resident R2 has behaviors related to bipolar disorder, becomes anxious with agitation, has verbal outbursts, yelling and demanding of others, makes hateful/inappropriate comments, and mocking others. Resident R3's MDS dated [DATE REDACTED] documents Resident R3 has short and long term memory impairment and is moderately impaired with cognitive skills for daily decision making. Resident R3's active Care Plan documents Resident R3's diagnoses include Dementia and Paranoid Schizophrenia, and a problem dated 7/25/25 that Resident R3 wanders the hallways, violates the personal space of others, does not comprehend social limits and may be combative with staff.

On 11/17/25 at 1:10 PM Resident R2 was in her wheelchair in her room. There was a mesh barrier across Resident R2's doorway with a stop sign that said, Do Not Enter. Resident R2 stated Resident R3 gets in people's rooms and sleeps in their beds and the facility hasn't done much about it. Resident R2 stated there was one time that Resident R3 got physical with Resident R2

on an unidentified date. Resident R3 tried to go into Resident R2's room, Resident R3 banged on my (Resident R2's) arm, so I (Resident R2) banged her (Resident R3) back in the arm.

On 11/17/25 at 9:36 AM Resident R3 was sitting in the recliner in Resident R3's room. Resident R3 responded to name only but did not respond to any questions.

On 11/17/25 at 1:27 PM V8 CNA confirmed V8 witnessed Resident R2's/Resident R3's altercation on 10/16/25. V8 stated the following: The incident happened between 2:00 PM and 2:30 PM. V8 witnessed Resident R2 coming down the hallway from Resident R2's room towards the nurse's station. Resident R2 was in the middle of the hallway and Resident R3 came up behind Resident R2. Resident R2 does not like people Resident R2's personal space and Resident R3 wanders and likes to go into other resident rooms and lay in their beds. Resident R2 may have thought Resident R3 was in Resident R2's room. As Resident R3 wheeled passed on the right side of Resident R2, between the railing and Resident R2, Resident R3 grabbed the arm rest of Resident R2's wheelchair to propel herself. Resident R2 got upset, yelled at Resident R3 and slapped Resident R3 in the right hand three times reprimanding Resident R3 like you would a child. Resident R2's hit was intentional. Resident R3 did not seem fazed or affected by Resident R2. V8 told Resident R2 that Resident R2 should have waited since V8 was coming to assist Resident R2. Resident R2 swears that Resident R3 hit Resident R2 first, but V8 did not see Resident R3 hit Resident R2. V8 stated Resident R3 may have accidentally bumped Resident R2 when Resident R3 grabbed Resident R2's arm rest. Resident R2 is with it, knows staff, and is alert/oriented to person, place, time and situation. Resident R3 is confused and in her (Resident R3's) own world.

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

Event ID:

Facility ID:

If continuation sheet

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

11/18/2025

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to provide a 30-day notice for an involuntary discharge for one of one resident (Resident R1) reviewed for involuntary discharge in the sample list of seven.Findings includeThe facility's Immediate/Emergency Transfer and Discharge Policy dated September 2016 states To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician's orders, and in such a manner as to maintain continuity of care for the resident.The Physician Order Sheet dated November 2025 documents Resident R1 has the following diagnoses: Schizoaffective Disorder, Varicella without complications and Drug Induced Subacute Dyskinesia.Resident R1's Minimum Data Set (MDS) assessment dated [DATE REDACTED] documents, BIMs (Brief Interview for Mental Status) of 15, cognitively intact. The Facility Incident Report Final Report dated 11/15/25 documents Resident R1 exited the building on 11/10/25 at 5:10 AM through the Southwest exit door and was found in a field about three blocks from the facility at 6:15 am. EMS arrived and transported Resident R1 to the Emergency Department at the local hospital where Resident R1 was diagnosed with hypothermia.The Progress Note dated 11/12/25 at 5:15 PM documents V9, Social Service Designee and V1 Administrator delivered involuntary discharge papers to Resident R1 while at the hospital.V24, Brother of Resident R1 stated on 11/15/25 at 10:52 AM Yes I am the half brother of (Resident R1) and (Resident R1) can barely talk he has a speech problem. I asked him what happened and he won't tell me anything. I would call the facility and talk with him

on the phone, and (Resident R1) has been at the same facility for over 20 years.V1, Administrator stated in interview

on 11/15/25 at 2:30 PM, Yes (Resident R1) was delivered involuntary discharge papers because we are not a locked unit and (Resident R1) needs locked doors to keep him from exiting on his own. I told the hospital the facility would take him back as a resident if they would adjust his medication so (Resident R1) would not want to leave the building.

The facility does not have locked exit doors and this is how (Resident R1) was able to leave the building, through the southwest exit door.V20, Director of Care Services for the local hospital stated in interview on 11/18/25 at 9:30 AM The facility served (Resident 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 (Resident R1) is alert and oriented, decision making skills are there also but (Resident R1) would not be able to live alone. (Resident 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. (Resident R1) is his own person but he can not take care of himself. The Ombudsman organization is helping with the discharge process they are going to file for a hearing due to the involuntary discharge and the facility (Resident R1) was at is the only place (Resident R1) has been in the last 20 some years.V19, Nurse Practitioner for the contracted company who works with the mental health clients for the facility stated in interview on 11/18/25 at 12:02 PM, I agree with the assessment (Resident R1) received at the hospital.

Event ID:

Facility ID:

If continuation sheet

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

11/18/2025

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 0744

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or potential for actual harm

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

observation, interview, and record review the facility failed to implement care planned interventions for dementia related wandering behavior for one of four residents (Resident R3) reviewed for abuse in the sample list of seven. Findings include:The facility's undated Abuse Prevention Policy documents Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.The facility's State of Illinois Illinois Department of Public Health Long-Term Care Facility & IID -Serious Injury Incident Report dated 10/23/25 at 4:10 PM documents on 10/16/25 at 2:20 PM Resident R2 open handed smacked Resident R3 on Resident R3's right upper arm. Resident R2 stated Resident R2 acted in retaliation claiming that Resident R3 hit Resident R2 first, however witnesses did not support that Resident R3 hit Resident R2. V8 Certified Nursing Assistant (CNA) written Witness Statement dated 10/16/25 documents V8 was coming out of the CNA room and Resident R3 grabbed onto the armrest of Resident R2's wheelchair and Resident R2 started smacking Resident R3's arm. V8 immediately separated Resident R2 and Resident R3. Resident R3's MDS dated [DATE REDACTED] documents Resident R3 has short and long term memory impairment, is moderately impaired with cognitive skills for daily decision making and wanders. Resident R3's active care plan documents Resident R3's diagnoses include Dementia and Paranoid Schizophrenia, and a problem dated 10/25/23 that Resident R3 wanders the hallways, into other resident rooms and gets into unoccupied beds. Interventions include to provide structured activities such as toileting, walking inside and outside, and reorientation strategies including signs, pictures and memory boxes.On 11/17/25 at 9:36 AM Resident R3 was sitting in the recliner in Resident R3's room. Resident R3 responded to name only but did not respond to any questions. There were no pictures, memory boxes, or signs in Resident R3's room or near the outside of Resident R3's doorway to help Resident R3 identify Resident R3's room. There was only a standard name plate that is used for all residents, with Resident R3's first initial and last name located near Resident R3's doorway. On 11/17/25 at 11:55 AM V14 CNA stated Resident R3 wanders and goes into other resident rooms. V14 stated we try to redirect Resident R3 and Resident R3 is also on 15-minute visual checks. V14 stated Resident R3 relaxes in Resident R3's recliner and enjoys watching television. V14 stated Resident R3's name is outside Resident R3's room door. V14 confirmed this is the same for all residents and lists first initial only. V14 went to Resident R3's room and confirmed there are no pictures, shadow boxes, or signs to identify Resident R3's room. V14 stated signs have been used on room doors to help other residents identify their rooms, but this has not been done for Resident R3. On 11/17/25 at 1:27 PM V8 CNA confirmed V8 witnessed Resident R2's/Resident R3's altercation

on 10/16/25. V8 stated the incident happened between 2:00 PM and 2:30 PM. Resident R2 does not like people in Resident R2's personal space and Resident R3 wanders and likes to go into other resident rooms and lay in their beds. Resident R2 may have thought Resident R3 was in Resident R2's room. As Resident R3 wheeled passed on the right side of Resident R2, between the railing and Resident R2, Resident R3 grabbed the arm rest of Resident R2's wheelchair to propel herself. Resident R2 got upset, yelled at Resident R3 and slapped Resident R3 in the right hand three times reprimanding Resident R3 like you would a child. Resident R3 had room changes over the last year and since then Resident R3's wandering has been worse. Resident R3 does recognize things in her room, likes her jewelry and bedding. V8 was asked if any pictures or signs had been used to help Resident R3 identify her room. V8 stated that is a good idea, that might help Resident R3 recognize Resident R3's room. V8 confirmed pictures and signs had not been used.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

11/18/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on interview and record review the facility failed to document a resident to resident altercation in the electronic medical record for two of four residents (Resident R2, Resident R3) reviewed for abuse in the sample list of seven.

Findings include:The facility's State of Illinois Illinois Department of Public Health Long-Term Care Facility & IID -Serious Injury Incident Report dated 10/23/25 at 4:10 PM documents on 10/16/25 at 2:20 PM Resident R2 open handed smacked Resident R3 on Resident R3's right upper arm. Resident R2 stated Resident R2 acted in retaliation claiming that Resident R3 hit Resident R2 first, however witnesses did not support that Resident R3 hit Resident R2. Resident R2's and Resident R3's electronic medical records (EMRs) did not include documentation of the 10/16/25 altercation. On 11/17/25 at 1:10 PM Resident R2 stated Resident R3 gets in people's rooms and sleeps in their beds and the facility hasn't done much about it. Resident R2 stated there was one time that Resident R3 got physical with Resident R2 on an unidentified date. Resident R3 tried to go into Resident R2's room, Resident R3 banged on my (Resident R2's) arm, so I (Resident R2) banged her (Resident R3) back in the arm. On 11/17/25 at 1:27 PM V8 CNA confirmed V8 witnessed Resident R2's/Resident R3's altercation on 10/16/25. V8 stated the incident happened between 2:00 PM and 2:30 PM. V8 witnessed Resident R3 wheel past and grab onto Resident R2's wheelchair armrest. Resident R2 got upset with Resident R3, yelled at Resident R3 and slapped Resident R3 in the right hand three times reprimanding Resident R3 like you would a child. Resident R2's hit was intentional. V8 described Resident R2 as being with it, knows staff, and alert/oriented to person, place, time and situation. V8 stated Resident R3 is confused and in her (Resident R3's) own world. On 11/17/25 at 12:05 PM V5 Licensed Practical Nurse was asked where V5 documented Resident R2's/Resident R3's incident in their EMR. V5 stated to ask V2 Director of Nursing (DON) since V2 took over the incident, and all V5 documented was that Resident R2 was on initial constant supervision which changed to 15-minute checks. On 11/17/25 at 2:05 PM V2 DON stated resident to resident altercations are documented in risk management and confirmed this incident was not documented

in Resident R2's or Resident R3's EMRs. V2 stated V5 was Resident R2's nurse that day and would have made the notifications to the family and physician, which V5 usually documents in a progress note. V2 stated V15 Registered Nurse may have notified Resident R3's family and physician, and all of this would be documented in risk management. On 11/17/25 at 3:40 PM V1 Administrator stated resident to resident altercations are documented in risk management and V1 thought staff documented the incident in the EMR in a progress note. The facility's undated Abuse Prevention Policy documents all incidents will be documented, whether or not abuse occurred, was alleged or suspected.

Event ID:

Facility ID:

If continuation sheet