Inspection·February 7, 2025

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 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. Findings include: The facility undated policy titled Abuse Prevention Policy documents abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. 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, such as telling a resident that he/she will never to be able to see his/her family again. 1. R2's undated Face Sheet documents medical diagnoses of Depression, Bipolar Disorder, Traumatic Brain Injury, Heart Failure, Prosthetic Heart Valve, Atrial Fibrillation and Cardiac Pacemaker. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 requires set up assistance for eating, dressing, toileting, oral hygiene, bathing and is independent in bed mobility and transfers. This same MDS documents R1 was able to walk 150 feet independently. R2's Final Report to State Agency dated 12/26/24 documents on 12/21/24 at 12:00 PM R1 was yelling out in the dining room. This same report documents (R1) began cussing and yelling in the dining room stating 'I'm going to kill all of you. (R2) stated she didn't know why (R1) was upset but that they (R1, R2) exchanged words. In conclusion, it was determined that the resident to resident (R1, R2) altercation did occur however, neither resident sustained any injuries. On 2/6/25 at 11:40 AM R2 stated R1 was mean to everyone. R2 stated R1 would yell and cuss and scare R2 and other residents. R2 stated R1 told R2 that he was going to kill her and then tried to throw a walker at another (unknown) resident so R2 got up and tapped R1 on the shoulder to remind R2 that he cannot act like that. R2 stated (R1) was cussing and scaring me and all the residents and the (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 5 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 02/07/2025 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)