Inspection·November 8, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based 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. Findings include: R28's Level 2 PASRR to evaluate for the need of specialized mental health services dated 8/17/2015 documents R28 had a history of inpatient mental health hospitalizations, experienced delusions, irritability, and difficulty remaining on tasks related to her medical diagnosis of Paranoid Schizophrenia. This Level 2 screening had a determination date of 8/24/2015 and documented R28 required specialized services including mental health rehabilitation services, illness self-management, and community re-integration activities. This Level 2 screening documented this determination was valid for 90 days from the date of determination (11/22/2015), and a new determination should be obtained from the entity treating the individual on 11/22/2015. On 11/7/24 at 10:08 AM, V10, Business Office Manager, and V7, Social Services Director, stated they did not have any documentation more current than the Level 2 PASRR from 8/17/2015. At 10:31 AM, V10 stated, I called the (screening agency) and they did not have any records of a more recent screening. V10 further stated, The Level 1 screening is good for 30 days so the resident would have to be admitted to the facility within that 30 days, but the Level 2 can be limited to 90 days and then they would need another Level 2 in that 90 days. 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 6 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 11/08/2024 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)