Arcadia Care Havana

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Based on record review and interview the facility failed to provide financial statements quarterly to residents and residents' representatives. This failure has the potential to affect all 44 residents residing within the facility. Findings include:The Resident Funds policy dated 3/2024 documents Guidelines: 5. The resident and/or resident representative is provided with a quarterly accounting report of his or her funds on deposit with the facility, and upon request.The Business Office Manager policy dated 7/2023 documents, Job duties: Prepare and mail statements.On 8/6/25 at 8:45 AM V7 (Resident R1's Power of Attorney) stated, I have never received a copy of (Resident R1's) financial statement from the facility.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, I worked for the facility from the day the company took over on 11/1/24 until I was terminated on 6/12/25. While I was there, I never provided the residents or residents' representatives with quarterly financial statements. I used to mail those for the prior company, but since I started with this company I did not have time to as I was doing three different jobs there.On 8/6/25 at 11:30 AM V3 (Business Office Manager) stated, I just started a little over a month ago. I have not had a chance to send out quarterly financial statements to the residents or residents' representatives.On 8/6/25 at 1:55 PM Resident R2 stated, I don't think I have every received a financial statement.On 8/6/25 at 2:30 PM V1 (Administrator) stated, One of the reasons (V6) was terminated was due to (V6) not doing her job. (V6) knew she should have been sending out quarterly financial statements to the residents and families and was not.The facility's Daily Census Report dated 8/6/25 documents 44 residents currently reside within the facility.

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

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Havana

609 North Harpham Street Havana, IL 62644

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 0569

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview the facility failed to refund unused resident funds to a resident's representative within 30 days of the resident's death for one of three residents (Resident R1) reviewed for resident funds in the sample of three.Findings include:The Illinois Department on Aging Centers for Medicare and Medicaid Understating Your Financial Rights Guidelines dated 7/12/21 document, Your financial rights: The nursing home must return funds with a final statement to the person or court handling your estate within 30 days after your death. Resident R1's Hospital Record documents:Resident R1 was transferred to the hospital from the facility

on 6/21/25 and passed away while in the hospital on 6/23/25.Resident R1's Resident Statement Landscape dated 11/5/24 through 6/12/25 documents Resident R1 had 60.00 dollars each month deposited by SSA (Social Security Administration) into the facility's trust fund account for Resident R1's personal use. Resident R1's Resident Statement Landscape dated 8/1/25 documents Resident R1 had 420.00 personal dollars left in the facility's trust fund account that Resident R1 had not spent or used since 11/5/24.On 8/6/25 at 8:45 AM V7 (Resident R1's Power of Attorney) stated, I have been asking since 7/8/25 for the facility to refund (Resident R1's) remaining funds. The facility has yet to refund

the funds, and I feel like I am getting the run around.On 8/8/25 at 11:30 AM V15 (Regional Director of Operations) stated, The facility does not have a policy on when remaining trust funds are distributed to the residents' representatives, however we (the facility) follow CMS (Centers for Medicare and Medicaid Services) guidelines. (V7/Resident R1's Power of Attorney) should have received (Resident R1's) remaining 420.00 dollars left

in the facility's trust fund within 30 days after (Resident R1's) death (6/23/25). The facility has not sent out the 420.00 dollars yet.

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

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Havana

609 North Harpham Street Havana, IL 62644

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 0572

Give residents a notice of rights, rules, services and charges.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview the facility failed to promptly provide a copy of the updated admission agreement/contract to all residents and/or residents' representatives upon change of facility ownership.

These failures have the potential to affect all 34 residents residing within the facility upon change of ownership on 11/1/24.Findings include:The facility's Daily Census Report dated 11/1/24 documents 34 residents residing within the facility on 11/1/24. The Business Office Manager policy dated 7/2023 documents Business Office Manager Job Description Summary: The primary purpose of the Business Office Manager is to assist in the day-to-day accounting functions of the facility in accordance with current acceptable accounting and cost reimbursement principles relating to nursing facility operations, and as may be directed by the Administrator, Director of Finance, or Accountant. Ensure that resident admission contracts are signed and appropriately filed.V5's (Prior Business Office Manager's) Performance Improvement Plan dated 4/28/25 documents V5 was responsible for doing admission contracts with the residents and residents' representatives and was not doing the admission contracts within 24-48 hours of

the residents' admission. On 8/9/25 at 8:30 AM V1 (Administrator) provided a list of all residents residing within the facility upon change of ownership on 11/1/24 with the date of when the admission contract was provided to the residents or residents' representatives. According to this list, none of the 34 residents residing within the facility on 11/1/24 received the facility's admissions agreement within 30 days.On 8/6/25 at 1:38 PM V8 (Resident R3's Guardian) stated, I did not sign (Resident R3's) admission contract until months after (the facility) took ownership.On 8/7/25 at 11:30 AM V1 (Administrator) verified none of the residents' admission contracts were signed or given to the residents or residents' representatives immediately, or within 30 days, upon the facility taking over ownership on 11/1/24.

Residents Affected - Many

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

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Havana

609 North Harpham Street Havana, IL 62644

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 0602 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (Resident R3) and take (Resident R3) out to dinner. V8 also confirmed he has been using Resident R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) should have tried to protect Resident R3's funds from being exploited by V8 when V6 first became aware (March 2025).The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (Resident R2's guardian) was exploiting Resident R2's funds and failed to protect Resident R2 from further exploitation. V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM.On 8/9/25 and 8/11/25 this surveyor confirmed through interview and record review that the facility took the following actions to remove

the Immediate Jeopardy:1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1

on the facility's abuse policy regarding immediately reporting and investigating abuse.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding the facility's abuse policy and procedures.4.On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with Abuse and Misappropriation of resident funds.5.On 8/8/25 V1 provided all families with a copy of the facility's Abuse Policy by certified mail.6.On 8/8/25 V18 (Activity Director) in-serviced all residents regarding the facility's abuse policy and procedures.7.On 7/31/25 V1 notified the Social Security Administration and Resident R2's social security funds were suspended.8.On 8/8/25 V1 notified the Social Security Administration and Resident R3's social security funds were suspended.9. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for Resident R3's long term disability check to be sent directly to Resident R3 in care of (the facility) due to exploitation of finances by (V8/Resident R3's Guardian).10. Resident R2 no longer requires a Guardian, and the facility is currently working with Resident R2 to appoint Resident R2 a power of attorney in the event Resident R2 is no longer able to make her own healthcare decisions. 11.On 8/8/25 V1 contacted the facility's legal department and Office of State Guardianship to file a petition to change Resident R3's Guardian. 12. On 8/8/25 V3 (Business Office Manager) sent all residents and residents' representative current financial statements by certified mail.13.

On 8/8/25 V3 (Business Office Manager) reported all discrepancies of residents' payments not being made to V1, and V1 reported all discrepancies of resident payments not being made to the local police and state agency.Completion Date: 8/8/25.

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

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Havana

609 North Harpham Street Havana, IL 62644

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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

Security Income) and Disability and believed the case with be Social Security/Medicaid Fraud.On 8/6/25 at 11:02 AM V6 (Prior Business Office Manager) stated, While I was working at the facility, (V8/Resident R3's Guardian) stopped paying the entire amount for (Resident R3's) bill to the facility. (V8) was the representative payee for (Resident R3's) social security check. I was supposed to do (Resident R3's) Medicaid recertification sometime around March 2025 and noticed (Resident R3) was also getting a disability check from prior employment. (V8) had never been turning

the disability check money over. I recall (Resident R3's) disability check being over 1,000.00 dollars per month. I stuck the information in (Resident R3's) file and never got time to deal with (V8) not paying the facility. I figured (V8) was spending (Resident R3's) money. I never reported this to the administrator. On 8/6/25 at 1:38 PM V8 (Resident R3's Guardian) stated, (Resident R3) has been getting a check from long-term disability for years. The facility has always been aware. In fact, back in March (V6/Prior Business Office Manager) told me to keep it and not worry about it, and the facility would never find out about it. I have been using the check to come and see (Resident R3) and take (Resident R3) out to dinner. V8 also confirmed he has been using Resident R3's long-term care disability checks to buy V8 and his family personal items, to pay taxes, and to pay personal credit card accounts.On 8/7/25 at 10:20 AM V4 (Prior Administrator) stated, (V6/Prior Business Office Manager) never reported anything to me while I worked at the facility about (V8) taking (Resident R3's) funds and not paying (Resident R3's) bill.On 8/7/25 at 11:30 AM V1 (Administrator) verified V6 (Prior Business Office Manager) never made V1 aware of V6's suspicion that V8 was exploiting Resident R3's funds. V1 verified V6 should have reported the suspicion that V8 was exploiting Resident R3's funds when V6 first became aware in March 2025. V1 confirmed she was not made aware, and the state agencies and local police were not made aware until V3 (Current Business Office Manager) reported

the allegation to V1 on 7/2/25. The Immediate Jeopardy started on 1/29/25 when V5 (Prior Business Office Manager) first suspected V11 (Resident R2's guardian) was exploiting Resident R2's funds and failed to report this to the Administrator, therefore the local police and state agencies were not notified immediately upon suspicion.

V1 (Administrator) and V15 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 8/8/25 at 8:10 AM. On 8/9/25 this surveyor confirmed through interview and record review that

the facility took the following actions to remove the Immediate Jeopardy: 1.On 8/8/25 V3 (Business Office Manager) and V5 (Regional Financial Coordinator) completed a 100 percent audit of all resident trust funds to ensure all residents' accounts were paid up to date and all discrepancies were immediately investigated.2.On 8/8/25 V15 (RDO) educated V1 on the facility's abuse policy regarding immediately reporting abuse.3.On 8/8/25 V1 (Administrator) and V17 (MDS Coordinator) in-serviced all staff regarding

the facility's abuse policy and procedures.4. On 8/8/25 V1 held a QA (Quality Assurance) meeting with the Inter-Disciplinary Team to ensure compliance with reporting Abuse and Misappropriation of resident funds.5.On 7/31/25 V1 notified the Social Security Administration and Resident R2's social security funds were suspended.6.On 8/8/25 V1 notified the Social Security Administration and Resident R3's social security funds were suspended.7. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for Resident R3's long term disability check to be sent directly to Resident R3 in care of (the facility) due to exploitation of finances by (V8/Resident R3's Guardian).8. On 8/8/25 V3 (Business Office Manager) reported all discrepancies of residents' payments not being made to V1, and V1 reported all discrepancies of resident payments not being made to

the local police and state agency.Completion Date: 8/8/25.

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

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Havana

609 North Harpham Street Havana, IL 62644

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 0610 Level of Harm - Immediate jeopardy to resident health or safety

security funds were suspended.6.On 8/8/25 V1 notified the Social Security Administration and Resident R3's social security funds were suspended.7. On 8/8/25 V1 contacted The Guardian Life Insurance Company of America to ask for Resident R3's long term disability check to be sent directly to Resident R3 in care of (the facility) due to exploitation of finances by (V8/Resident R3's Guardian).8. On 8/8/25 V3 (Business Office Manager) sent all residents and residents' representative current financial statements by certified mail.9. On 8/8/25 V1 provided all families with a copy of the facility's Abuse Policy by certified mail.Completion Date: 8/8/25.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet