The Haven of Arcola

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident's right to be free from physical and sexual abuse by other residents. The failure affects four of four residents (R2, R3, R4, R5) reviewed for abuse on a sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to provide a 30-day notice for an involuntary discharge for one of one resident (R1) reviewed for involuntary discharge in the sample list of seven.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care planned interventions for dementia related wandering behavior for one of four residents (R3) reviewed for abuse in the sample list of seven.

Inspectors wroteBased 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 (R2, R3) reviewed for abuse in the sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to safely provide a resident wheelchair assistance, while obtaining a resident's weight, in a manner to prevent a fall. This failure resulted in a vertebra fracture for one of three residents (R1) reviewed for falls on the sample list of three. This past noncompliance occurred from 8/12/25 through 8/12/25.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a registered nurse for eight consecutive hours seven days a week every twenty-four hours. This failure has the potential to affect all 65 residents who reside in the facility. The Long-Term Care Facility Application for Medicare and Medicaid dated 9/7/25 documents 65 residents reside at the facility. The facility's Staffing Policy that is not dated was provided by V1 Administrator and documents that a Registered Nurse (RN) will be scheduled seven days a week at least one continuous (8) eight-hour shift. The facility's nursing work schedule for the month of August 2025 and September 2025 documents the facility did not have the services of a RN for eight consecutive hours on 8/25/25, 8/30/25, and 9/10/25. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement interventions and monitoring for hyponatremia (low sodium) with repeated hospitalizations for one of three residents (R40) reviewed for hospitalizations in the sample list of 33. R40's Minimum Data Set (MDS) dated [DATE] documents R40 has moderate cognitive impairment. R40's September 2025 Medication Administration Record (MAR) documents R40 receives the following psychotropic medications: Fluoxetine 60 milligrams (mg) by mouth (PO) daily, Mirtazapine 15 mg PO daily, Olanzapine 22.5 mg PO daily, Divalproex 500 mg PO twice daily, and Clorazepate Dipotassium 7.5 mg PO daily. R40's emergency room Discharge Instructions dated 5/2/25 documents the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP), perform hand hygiene, properly disinfect equipment and maintain a urinary catheter bag off the floor for three of 17 residents (R12, R40, R43) reviewed for infection control in the sample list of 33. 1.) On 9/07/2025 at 8:31 AM R40's door contained a sign indicating R40 was on EBP and to wear gown and gloves for high contact care, including assistance with dressing, transfers, and care of indwelling devices. PPE (Personal Protective Equipment) was present in a container on R40's door. R40 was lying in bed and R40's urinary catheter drainage bag was on the side of the bed. R40 stated R40 has had the catheter for a few months and has had urinary tract infections (UTIs). R40 stated the staff do not wear gown and gloves when providing R40's cares. [...]

Inspectors wroteBased on interview and record review the facility failed to honor a female resident's request to have her shower done by female staff for one (R14) of one resident reviewed for choices on a sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to provide quarterly statements of personal funds accounts for two of two residents (R4, R8) reviewed for personal funds in the sample list of 33The facility's undated Quarterly Trust Statements Policy documents quarterly statements are sent out by the last day of the following month by the business office. This policy documents to make two copies of the statements, one to keep for records and one to give to the resident/responsible party. This policy documents to keep a spreadsheet and indicate next to the resident's name when a copy was mailed to the resident's representative, and attach a copy of the statement. This policy documents to have the resident sign his/her name on the spread sheet to indicate they received their quarterly statement and upload a copy of the statement into the resident's electronic medical record. [...]

Inspectors wroteBased on interview and record review the facility failed to provide written notice of transfer and bed hold for hospitalizations for one of three residents (R13) reviewed for hospitalizations in the sample list of 33. The facility's Bed Hold and readmission Policy dated November 2016 documents it is the facility's policy to readmit residents after hospitalization and the facility will hold a specific bed or make available the next semi-private accommodation if the resident chooses not to hold the specific bed. This policy documents the resident/representative shall be informed of this policy on admission and at the time of transfer to a hospital, and provided written notification at the time of transfer. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assess/measure a pressure sore, administer a wound treatment according to physician's orders and accurately document the location of a pressure sore for one resident (R12) of two residents reviewed for pressure sores in a sample list of 33. Findings Include: R12's Care Plan updated 6/16/25 lists the following diagnoses: Hypomagnesemia, Chronic Pulmonary Edema, Quadriplegia, C5-C7 Complete, Neuromuscular Dysfunction of Bladder, Seizures, Cauda Equina Syndrome, Zoster Encephalitis, and Primary insomnia. R12's MDS Minimum Data Set, dated [DATE] documents R12 is cognitively intact. R12's admission Skin assessment dated [DATE] documents a Superficial wound (to the) Right Gluteal Fold measuring 0.2cm (centimeters) in Length by 0.2cm in width by 0cm in depth. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have physician's orders for the use and care of Continuous Positive Airway Pressure (CPAP) for one of one resident (R25) reviewed for CPAP use in the sample list of 33. The facility's CPAP/BiPAP (Bilevel Positive Airway Pressure) Support policy dated April 2007 documents to review the physician's order to determine the oxygen flow rate and positive end-expiratory pressure settings. This policy includes to document a general assessment prior to the procedure, time/duration of therapy, CPAP settings, oxygen flow rate, oxygen saturation, and how the resident tolerated the procedure. On 9/07/2025 at 9:27 AM There was a CPAP machine on the overbed table next to R25's bed. The CPAP mask and tubing was in a plastic bag attached to the machine. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure physician visits are documented for one of three (R40) residents reviewed for hospitalization in the sample list of 33. The facility's undated Physician Services Policy documents It is the policy of this facility that each resident admitted to this facility is under the care of a physician licensed in the State and that all physician services will comply with State and Federal regulations for resident care in a licensed facility. The attending physician shall write a progress note at the time of each resident visit and review the resident's total program of care; i.e. (in other words) comprehensive assessments, care plans, medication and treatments, and approving such by signing and dating the current order recap. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure timely physician visits for one of three residents (R40) reviewed for hospitalizations in the sample list of 33. The facility's undated Physician Services Policy documents It is the policy of this facility that each resident admitted to this facility is under the care of a physician licensed in the State and that all physician services will comply with State and Federal regulations for resident care in a licensed facility. The attending physician shall write a progress note at the time of each resident visit and review the resident's total program of care; i.e. (in other words) comprehensive assessments, care plans, medication and treatments, and approving such by signing and dating the current order recap. [...]

Inspectors wroteBased on interview and record review the facility failed log infections, organisms, and antibiotics and ensure the appropriate antibiotics were administered for one (R40) of five residents reviewed for infection control on a sample list of 33.

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to privacy. This failure affected two of four residents (R1, 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. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. [...]

Inspectors wroteBased 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 (R1, 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. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident with known physical behaviors for two of four residents (R1, R2) reviewed for abuse in the sample list of seven residents. This failure resulted in R2 experiencing physical trauma including a lacerated lip, swollen eye, and multiple scratches, and fear of R1 causing R2 to refuse emergency services due to fear of R1 attacking R2 in the hospital after R1 punched R2 multiple times. This past non-compliance occurred from 7/18/25-7/25/25. R2's Electronic Medical Record (EMR) documents medical diagnoses as Schizoaffective Disorder, Paranoid Personality Disorder, Dementia with Agitation, Extra Pyramidal and movement disorder and Paranoid Schizophrenia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident dignity for three of three residents (R4, R5, R6) reviewed for dignity in a sample list of seven residents. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. This same MDS documents R4 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene and bed mobility. 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 R4's behaviors of consensual sexual behavior with male peers prior to 7/29/25. This same care plan documents R4 requires a wheelchair for mobility. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by another resident. This failure affects two of four residents ( R2 and R7) reviewed for abuse in a sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to report allegations of verbal abuse to the Abuse Coordinator for three of four residents (R1, R2, R7) reviewed for abuse in a sample list of eight residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse for eight consecutive hours per day seven days per week. This failure has the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during medication administration for four residents (R13, R56, R51, R270) out of six reviewed for medication administration in a sample list of 31 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain a new Level 2 PASRR (Preadmission Screening and Resident Review) to evaluate a resident's need for specialized mental health services upon the expiration of the initial Level 2 evaluation. This failure affects one resident (R28) out of 11 reviewed for pre-admission screening on the sample list of 31.

Inspectors wroteBased on interview and record review the facility failed to complete a baseline careplan timely for one resident (R270) out of one reviewed for careplans in a sample list of 31 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned post fall interventions for fall prevention. This failure affects one resident (R59) out of seven reviewed for falls on the sample list of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R12) of five reviewed for bed side rails in the sample list of 31.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's (R2) right to be free from abuse by another resident (R1). This failure affects three (R1, R2, R3) of seven residents reviewed for abuse in the sample list of seven.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the administrator. This failure affects two (R2, R3) of seven residents reviewed for abuse in the sample list of seven.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are free from significant medication errors, by failing to correctly identify a resident prior to medication administration. This failure affects one resident (R1) out of seven reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to operationalize their abuse prevention policy by failing to document identified interventions for five (R2, R3, R4, R5 and R6) of nine residents reviewed for abuse from a total sample list of nine residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure therapy services were provided for six residents (R2, R4, R19, R20, R21, R22) of six residents reviewed for therapy services on the sample list of 22.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free of verbal and physical abuse by another resident for two of three residents (R8 and R9) reviewed for abuse in the sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to follow physician discharge orders for two residents (R2, R3) of three residents reviewed for following physician discharge orders in the sample list of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a properly functioning call light system for four (R1, R5, R6, R7) residents out of four residents reviewed for call lights in a sample list of seven residents.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal and mental abuse by staff for two of four residents (R1, R2) reviewed for abuse in a sample list of seven residents.

Inspectors wroteBased on interview and record review the facility failed to timely report allegations of abuse to the abuse coordinator for two of four residents (R1, R2) reviewed for abuse in a sample list of seven residents.

Inspectors wroteBased on interview and record review the facility failed to ensure a staff member was removed from resident care after an allegation of staff to resident abuse for one of one residents (R2) reviewed for abuse on the sample list of seven.

Inspectors wroteBased on observation, interview and record review the facility failed to use a gait belt during a resident's transfer and ambulation to prevent a fall for one (R40)of three residents reviewed for falls in the sample list of 44. The fall resulted in R40 sustaining a skin tear in the right arm.

Inspectors wroteBased on record review and interview the facility failed to follow residents' rights by not allowing residents to receive their mail on Saturdays. This failure has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to post daily staffing. This failure has the potential to affect all 77 residents residing in facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain resident rooms in a safe sanitary home like manner for five (R59, R53, R15, R42, R19) of 18 residents reviewed for environment in a sample list of 44 residents.

Inspectors wrote3.) R11's EHR documents R11's last completed and submitted Quarterly Minimum Data Set is dated 6/8/23. R11's Quarterly Minimum Data Set, dated [DATE] documents it is still in progress and has not been completed and submitted. Sections B, C, D and Q are incomplete on this assessment. Based on interview and record review the facility failed to complete quarterly Minimum Data Set assessments every three months for four (R53, R50, R11, R24) of 18 residents reviewed for Minimum Data Set assessments on the sample list of 44.

Inspectors wroteBased on interview and record review the facility failed to complete comphrehensive minimum data set assessments within 14 days of admission and every 12 months for two (R27, R178) of 18 residents reviewed for Minimum Data Set assessments on the sample list of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a resident centered psychiatric treatment plan for serious mental illness for two (R70, R59) of three residents reviewed for PASARR screens in a sample list of 44 residents. Findings Include: 1. On 10/2/23 at 12:06 PM, R70 was in R70's room which was on a locked unit designated for individuals with serious mental illness. R70's Pre-admission Screening and Resident Review (PASRR) dated 6/7/23 documents R70 suffers from Schizophrenia and requires specialized mental health care to treat this condition. R70's medical record does not document an interdisciplinary treatment plan to address R70's serious mental illness. On 10/4/23 at 10:00 AM V4, Care Plan Coordinator stated she was not aware individuals diagnosed with mental illness had to have a treatment plan. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop care plans with interventions for cigarette smoking. This failure has the potential to affect two of two residents (R8, R54) reviewed for smoking in a sample list of 44 residents. Findings Include: 1. On 10/2/23 at 10:30AM R8 stated I am going out to smoke. R8 was observed receiving a cigarette which was to be lighted when he went to the smoking area. R8's Smoking evaluation dated 6/28/23 documents Smoking materials kept by staff and dispensed at designated times. R8's Care Plan updated 8/23/23 does not include interventions to address R8's smoking.2. On 10/02/23 at 10:50 AM, R54 was smoking cigarettes in the smoking area unsupervised. R54's smoking assessment dated [DATE] documents R54 requires supervision while smoking. R54's Electronic Health Record does not contain a care plan for smoking.

Inspectors wroteBased on interview and record review the facility failed to complete psychotropic medication assessments for three (R49, R58, and R24) of five residents reviewed for psychotropic medications on the sample list of 44.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate contact and droplet isolation and conduct a PCR (Polymerase chain reaction) test when respiratory symptoms were present and failed to post isolation signs for two of two (R67, R128) residents reviewed for isolation on the sample list of 44.