Inspection·August 17, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. R1's Behavior Tracking for July 2025 through August 2025 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. R1 entered other resident's rooms or personal space 17 times in the last 30 days. R1's Care Plan dated 8/14/25 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal space of others, pacing, inappropriate comments, false allegations, manipulation, and insomnia. Staff are to intervene as necessary to protect the rights and safety of others. R2's Medical Diagnoses List dated August 2025 documents R2 is diagnosed with Schizoaffective Disorder, Generalized Anxiety disorder, Depression, Insomnia, and Paranoid Personality Disorder. R2's Care Plan dated 6/6/25 documents R2 is cognitively impaired and has short term memory deficit. R2 requires substantial/dependent assistance with activities of daily living. R2 is incontinent and requires staff to provide perineal care at least every two hours. On 8/17/25 at 2:27 PM V9 Certified Nurses Assistant stated R1 has a lot of anxiety and needs constant attention and reassurance. R1 will follow staff into other resident's rooms and will not listen when you ask her not to do things. R1 will invade other resident's privacy and is hard to redirect. R1will get into staff or resident's faces when asking them repetitive questions. V9 stated R1 will often open the curtain to talk to staff while they are providing personal care for R1's roommate (R2). V9 stated staff will have to stop what they are doing to redirect R1 and she continues to invade R2's privacy. On 8/17/25 at 2:37 PM V7 Licensed Practical Nurse stated R1 is constantly invading others' privacy and personal space. On 8/17/25 at 2:51 PM V6 Licensed Practical Nurse stated R1 bothers other residents and invades their privacy. On 8/17/25 at 4:45 PM V2 Director of Nurses stated she was not aware of R1 continually opening R2's privacy curtain while staff are providing care and confirmed that is a violation of R2's right to privacy. Residents Affected - Few 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 2 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 08/17/2025 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)