Inspection·August 20, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: The facility's Final Report dated 8/15/24 documents on 8/8/24 at 8:25 AM staff serving breakfast witnessed R2 grab R1's oatmeal and R1 hit R2 on the right side of R2's face with an open hand. R1 and R2 were immediately separated and there was no injury or redness noted. The investigative file for this incident included interviews with R3, V6 Certified Nursing Assistant (CNA) and V7 CNA that document they witnessed this incident and confirmed R2 grabbed R1's oatmeal and then R1 open handed smacked R2's face/head. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment and - BIMS 7, other behaviors occurred 1-3 days during review period. R2's MDS dated [DATE] documents R2 has short and long term memory loss. R2's Skin Evaluation dated 8/8/24 documents R2 was slapped on the face by another resident and there was no redness or injury. On 8/20/24 at 9:12 AM attempts were made to interview R2. R2 was confused and unable to give details regarding the incident with R1. On 8/20/24 at 9:17 AM R1 stated R1 vaguely recalled hitting a man a few weeks ago, and thought the man had been harassing a woman. R1 was unable to give any additional details regarding the incident with R2. On 8/20/24 at 9:39 AM R3 stated R3 was sitting at the table with R1 and R2 when the incident occurred. R3 stated R2 had taken R3's milk and spilled it on himself and the table, and then R2 grabbed R1's oatmeal. R3 stated R1 then slapped R2. R3 stated R1 hasn't done anything like that before, but R1 has a temper. On 8/20/24 at 1:34 PM V7 CNA stated the R1's/R2's incident occurred during breakfast, R1 and R2 were sitting at the same table next to each other. V7 stated R2 grabbed R1's oatmeal and then R1 smacked R2 in the head with an open palm. V7 stated R1's actions were intentional and not an accident. V7 stated R2 has a history of grabbing other residents' food and drinks, and now R1 and R2 have to be seated at separate tables and supervised. (continued on next page) 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 Page 1 of 3 Event ID: 146050 Printed: 05/15/2026 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 146050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2024 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)