Health inspection·March 21, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based 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. Findings include: The facility's abuse report dated 2/10/24, documents an altercation between R8 and R9. This report also documents R9 called R8 a derogatory name and R8 got up from her table and walked to R9's table and R8 pinched R9 on the right forearm. R8's current Electronic Medical Record (EMR) documents R8's diagnoses as: personal history of a Traumatic Brain Injury, Bipolar Disorder, and Depression. R8's Psychosocial Evaluation dated 1/3/24, documents R8 is easily distracted, has difficulty utilizing coping skills, difficulty with impulse control, difficulty with problem solving, has poor judgement, makes inappropriate comments, is depressed, anxious, and suspicious, and is physically aggressive. R8's Care Plan dated 3/12/24, documents R8 displays manipulative behaviors, is impatient, and has verbal outbursts. R9's current EMR documents R9's diagnoses as: Schizoaffective Disorder, Autistic Disorder, and Mild Intellectual Disabilities. R9's Psychosocial Evaluation dated 12/21/23, documents R9 has difficulty responding appropriately, boisterous, difficulty with impulse control, difficulty making decisions, difficulty with problem solving, demonstrates poor judgement, makes inappropriate comments, socially inappropriate, angry/aggressive, and suspicious. R9's Care Plan dated 10/20/23, documents R9 displays impaired coping and can be verbally and physically aggressive. On 3/10/24 at 10:35 AM, R8 stated R9 called her a derogatory name so R8 pinched R9's arm. On 3/10/24 at 10:45 AM, R9 stated R9 did call R8 a derogatory name but does not know why she did. R9 stated then R8 scratched R9 on the arm but did not draw blood. Page 1 of 6 146050 146050 03/21/2024 The Haven of Arcola 422 East Fourth Street Arcola, IL 61910

F 0600 Level of Harm - Minimal harm or potential for actual harm On 3/21/24 at 10:00 AM, V1 Administrator confirmed abuse did occur between R8 and R9 due to R9 calling R8 a derogatory name and then R8 pinching R9's arm. The facility's Abuse Prevention Program Policy dated Revised 11/28/2016, documents this facility affirms the right of the residents to be free from abuse. Residents Affected - Few 146050 Page 2 of 6 146050 03/21/2024 The Haven of Arcola 422 East Fourth Street Arcola, IL 61910

F 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Few Findings include: 1.) R2's current Electronic Medical Record (EMR) documents R2's diagnoses as: Osteomyelitis, wedge Compression Fracture of T11-T12 Vertebra subsequent encounter for fracture with routine healing, and Anemia. R2's Physician Order Sheet (POS) dated 1/1/24-1/31/24, documents Aspirin 81 milligrams (mg) oral tablet chewable, give one tablet by mouth one time a day and Apixaban (Eliquis) (anticoagulant-blood thinner) oral tablet 5 mg give one tablet by mouth two times a day with a start date of 11/1/23. There are no documented orders on this same POS to stop Apixaban (Eliquis) (anticoagulant) at any time. R2's Care Plan dated 2/27/24, documents R2 is on an anticoagulant. The Health Status Note dated 1/9/24 documents R2 had an unwitnessed fall in R2's room with a head laceration and R2 was sent the the Emergency Department. R2's Emergency Documentation notes dated 1/9/24, document to hold Eliquis (Apixaban) (anticoagulant) until seen by primary care provide and follow-up with primary care provider in the next 24-28 hours. On 3/9/24 at 2:28 PM, V5 Nurse Practitioner (NP) stated R2 should have seen R2's primary care doctor within 24-48 hours after R2's emergency room (ER) visit as ordered by the ER physician. V5 stated R2 should have had Eliquis held as ordered and then followed up with the primary doctor within 24-48 hours as ordered. V5 stated the nurses did not inform V5 of R2's incident or he would have made sure they were holding Eliquis until seen by R2's primary care doctor. V5 stated not holding Eliquis could cause a brain bleed if R2 fell again. On 3/19/24 at 11:52 AM, V10 Licensed Practical Nurse (LPN) stated R2's Apixaban (Eliquis) (anticoagulant) should have been held until R2 saw R2's primary care provider within 24-48 hours. V10 LPN stated R2's medical record does not document R2 being seen by R2's primary care provider within 24-28 hours from R2's ER visit on 1/9/24. V10 LPN confirmed from the Medication Administration Record (MAR) that R2's Eliquis (Apixaban) (anticoagulant) had not been held at any time in January 2024. V10 confirmed R2 was not seen by R2's primary care provider until 2/6/24. V10 LPN stated by not holding R2's Apixaban (Eliquis) (anticoagulant) R2 could have had a brain bleed. On 3/20/24 at 10:01 AM, V11 LPN confirmed R2's Apixaban (Eliquis) (anticoagulant) was not held any time in January 2024. V11 LPN stated V11 was at the facility when R2 returned from the ER but must have been passing medications and not looked at the discharge orders. V11 confirmed R2 did not see R2's primary care provider within 24-24 hours after R2's ER visit. V11 LPN stated R2 could have a brain bleed from continuing to take the anticoagulant Eliquis (Apixaban). 2.) R3's current EMR documents R3's diagnoses as: age-related Osteoporosis, Parkinsonism, and Body Dysmorphic Disorder. 146050 Page 3 of 6 146050 03/21/2024 The Haven of Arcola 422 East Fourth Street Arcola, IL 61910

F 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R3's After Visit Summary dated 1/23/24, documents R3 was seen 1/23/24 for injury of head and Urinary Tract Infection. This same After Visit Summary documents to schedule an appointment with R3's Medical Doctor as soon as possible for a visit in 2 days. On 3/9/24 at 2:28 PM, V5 Nurse Practitioner (NP) stated R3 should have seen R3's primary doctors with 24-48 hours after R3's emergency room (ER) visit as ordered by the ER physician. On 3/19/24 at 11:52 AM, V10 LPN stated there is no documentation in R3's medical record of being seen by the primary care provider within 24-28 hours after emergency room visit. On 3/20/24 at 10:01 AM, V11 LPN confirmed R3 did not see R3's primary care provider within 24-24 hours after R3's ER visit as ordered. On 3/20/24 at 12:58 PM, V1 administrator stated the nurses should review discharge orders when a resident is returned to the facility, put the orders in the EMR and make a progress note and notify the doctor with any new orders. V1 stated any order from a physician for a resident should be followed. The facility's Conformance with Physician Medication Orders Policy date Reviewed 9/27/17, documents all medications shall be given as prescribed by the physician. 146050 Page 4 of 6 146050 03/21/2024 The Haven of Arcola 422 East Fourth Street Arcola, IL 61910

F 0825 Provide or get specialized rehabilitative services as required for a resident. 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 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. Residents Affected - Some Findings include: 1. On 3/21/24 at 1:00 PM, R2 stated they quit giving R2 therapy and R2 does not know if they are going to start it again. R2 stated, when asked if R2 wants therapy, oh yes, I need to have it, I felt tremendously better when getting it. R2's Physician Order Sheet (POS) dated 12/1/23, documents Physical Therapy (PT) and Occupational Therapy (OT) evaluate and treat. R2's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 2. On 3/21/24 at 12:42 PM, R4 stated R4 used to get therapy and then it just quit and R4 wants to resume therapy. R4 stated R4 needs that help because R4 has fallen and R4 has to get therapy. R4 stated they have not told R4 when therapy will start back up and that R4 has not done therapy in a while. R4's POS dated 1/31/24, documents skilled occupational therapy three times a week for 4 weeks to include therapeutic exercise, self care, neuromuscular re-education, therapeutic activities, wheelchair management, and safety awareness. R4's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 3. On 3/21/24 at 12:53 PM, R19 stated R19 was getting therapy and it just stopped and R19 does not know when it will start back again. R19 stated R19 needs that therapy. R19's POS dated 2/13/24, documents PT evaluate and treat for therapeutic exercise, therapeutic activities, therapeutic activities, 5 times a week for 4 weeks. R19's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 4. On 3/21/24 at 12:49 PM, R20 was asked about therapy but R20 is not able to hold a conversation due to low cognition. R20's Minimum Data Set (MDS) dated [DATE], documents R20 is not cognitively intact. R20's POS dated 1/23/24, documents OT clarification skilled OT three times a week for 4 weeks to include therapeutic exercise, self care, neuromuscular re-education, therapeutic activities, wheelchair management, and safety awareness. R20's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 5. On 3/21/24 at 12:57 PM, R21 stated R21 used to get therapy but they don't have it anymore. R21 stated no one has told R21 when therapy would start again but that R21 wants therapy again. R21's POS dated 2/6/24, documents PT/OT evaluation and treat. R21's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 146050 Page 5 of 6 146050 03/21/2024 The Haven of Arcola 422 East Fourth Street Arcola, IL 61910

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. On 3/21/24 at 12:45 PM, R22 was asked about therapy but R22 is not able to hold a conversation due to low cognition. R22's Minimum Data Set (MDS) dated [DATE], documents R22 is not cognitively intact. R22's POS dated 12/15/23, documents OT clarification 3 times a week for 4 weeks for therapeutic exercise, group therapy, OT evaluation med complex, and therapeutic activities and PT clarification 5 times a week for 4 weeks for therapeutic exercise, neuromuscular education, gait training, and group therapy. R22's Therapy Past Appointments Sheet dated 2/17/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. On 3/19/24 at 1:06 PM, V1 administrator stated the last therapy day here was 2/18/24 and therapy started back again on 3/19/24 with another company, but they only saw R20 on 3/19/24. V1 stated therapy left here due to non-payment from us. On 3/21/24 at 1:42 PM, V15 Regional Director of (Therapy Provider) stated they have not officially started therapy yet at this facility. V15 stated we saw one person on 3/19/24 for an evaluation but nothing else has been done. V15 stated we don't even have staff to cover that facility yet for therapy so we are looking for staff. V15 stated they have not even received a list from the facility for who needs to be seen by therapy. V15 stated there is no set start date at this time. On 3/21/24 at 1:55 PM, V16 Regional Director of Operations stated we do not have a policy for therapy. V16 stated when we accept residents into the facility we except all their care needs including therapy. On 3/19/24, 3/20/24, and 3/21/24, no therapists were seen working in the therapy room. 146050 Page 6 of 6