Health inspection·October 9, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few the weight scale. (R1) will continue to work with therapy after his return to the facility.R1's admission Fall Care Plan dated 8/6/25 documents the following: FALLSThe resident is high risk for falls related to Gait/Balance problems. History of fall at home. Date Initiated: 08/06/2025. The resident will not sustain serious injury through the review date. Date Initiated: 08/06/2025. Anticipate and meet The resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Drop seat wheelchair. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Follow facility fall protocol. Pt evaluate and treat as ordered or PRN ( as needed).R1's same care plan was updated 8/12/25 as follows: ACTUAL FALLResident sustained an actual fall 8/12/25. Resident will resume normal activity through next review date. Target Date: 11/14/2025 8/12/25 ( Name brand non-skid material) in wheelchair. 8/12/25 sent to ER (Hospital, Emergency room).R1's Hospital Records dated 8/12/25 document the following: Chief ComplaintPatient (Pt) presents with Fall: Pt here for fall from wheelchair this morning at NH (nursing home, facility). Pt there ( at the facility) for rehab following a R (right) hip replacement ( due to a fall at home) performed here. Pt complains of pain all over but emphasizes his R hip. Poor historian as Alert x2 (alert to person and place, but not time) at baseline. Unsure if he (had) LOC (loss of consciousness).HPI (History of Present Illness): (R1) is a (specified age) male with medical history of Morbid Obesity, HFpEF (Heart Failure with Preserved Ejection Fracture), HLD ( Hyperlipidemia), OSA (Obstructive Sleep Apnea) , COPD (Chronic Obstructive Pulmonary Disease), T2 d ( Type II Diabetes Mellitus) , NASH ( Nonalcoholic) Cirrhosis, Peripheral Vascular Disease, History of Right Femoral Neck Fracture Status Post Right Hip Arthroplasty on 07/29/2025 (from fall at private home), and Gastric Angiodysplasia who presents to our facility with concerns of right hip pain and low back pain secondary to mechanical fall suffered falling off wheelchair today (8/12/25 at the facility), prior to arrival. Patient had ortho (orthopedic) surgery of the right hip on 07/29. Patient was discharged (from the hospital) on August 4th (8/4/25) to rehab (Rehabilitation, at the facility) , and today patient was being weighed on a scale and fell off the wheelchair, now reporting right hip pain. Denied having had any new numbness or weakness or tingling, has had some lower abdominal pain as well as right hip pain/lower back pain. Denies headache or neck pain. History was somewhat limited in the ER (Emergency Room), but per reports the patient denies any fevers, unclear if having worsening pain of the right hip over the last few days. Otherwise stating that patient is doing well, no other complaints at this time. R1's same Hospital Record dated 8/12/25 documents diagnoses addressed at the hospital included: Ground-level fall Closed fracture of first lumbar vertebra, unspecified fracture morphology, initial encounter. (non-surgical interventions)On 10/09/25 at 11:00 am R1 was lying in a low bed, on his back, with oxygen actively being administered. Multiple fall interventions were identified. R1's call light was in reach. One - quarter bedside rail was securely attached. A full, bed length, fall mat laid beside R1's bed. R1's wheelchair was close to the foot of R1's bed, in the locked position. R1's wheelchair cushion had nonskid fabric above and below. There was a wall sign present to remind resident to use his call light for assistance with transfers. R1 confirmed the interventions identified were in place because R1 had several falls in the facility. R1 stated an additional intervention for his falls included staff come into his room more frequently to ask him if he needs to go to the bathroom. R1 also stated the first fall he had was at his home. He fell and fractured right hip. R1 said his (unidentified family members) would have to give the details of that fall at home, as resident does not recall the event, until he woke up in the hospital post right hip surgery. R1 said that the first fall at home with the fracture, is the reason he had to be admitted to the facility 8/4/25, for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146050 If continuation sheet Page 2 of 4 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 10/09/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few therapy.R1 also stated he has had other falls in the facility, that were his own fault though, he can't recall the dates. R1 stated Twice I was getting up on my own. I should have asked for help. One fall I was horsing around in activities with another resident and the activity director. We were playing deal or no deal. At one point the activity staff had his head under a blanket reaching for prizes. I was just being silly. I was going to pour a little water on his head as he bent over. The other resident and I were cutting up. As I stood up with the glass of water, we were laughing. I tripped over my own feet, or maybe mine and his feet. I had a skin tear on my thumb is all. My pride was hurt. That was my own fault. I have also self-transferred in my room on those two separate occasions. They have a sign up (points to the wall sign) to remind me to use the call button for help. They also started the frequent bathroom offers. R1 also stated I had one fall that was the CNA's (later identified as V3, Certified Nursing Assistant) fault. She pulled my wheelchair backwards up the ramp of the scale. After she weighed me, the CNA let go of the wheelchair. I went down the ramp fast and went headfirst, and fell out of the wheelchair. I don't have any problem with my balance when seated. Usually, the CNA's will push me forward up the scale ramp, and back me down the slope after. They usually hold onto the wheelchair the whole time. Not that time. R1 then points across his room to the hallway. R1 said Look at ramp on the scale and you will see what I mean. It is right across the hall.On 10/09/25 at 11:15 am V5, Licensed Practical Nurse (LPN) entered a clean utility room where the platform wheelchair scale sat. There was platform approximately four foot wide, by four-foot-long wheelchair scale. The scale had a declining ramp off the platform that tapered approximately three to four inches down to the floor. V5, LPN confirmed the scale decline. V5, LPN stated residents are not safe to propel themselves forward down the sloped ramp. All CNA's know they are to push the resident up the ramp facing forward and pull the residents back down the ramp backwards, so they (residents) don't fall forward. Nursing staff all got educated that same day ( 8/12/25). Some by phone and some in person. We each had to return demonstration, to confirm understanding for safe weighing procedure. V5, LPN also stated (R1) has had a couple other falls self-transferring without injury. Het did sustain a lumbar fracture from the fall 8/12/25. He did not require surgical repair.On 10/9/ 25 at 11:55 am V2, Director of Nursing (DON) observed the facility, resident commercial, wheelchair weight scale in the clean utility room. V2, DON confirmed there was an approximately four-foot wide by four-foot-long weight platform, that sat at the top of a three-to-four-inch, sloped wheelchair ramp. V2, DON explained that the facility re- enacted the process V3, Certified Nursing Assistant (CNA) used to obtain R1's weight on 8/12/25. V2 stated she identified right away that V3, CNA had guided R1 up the ramp backward while R1 was facing forward. R1's wheelchair then rolled down the ramp with R1 facing forward. R1 fell forward out of the wheelchair. V2, DON then stated We (the facility) takes full responsibility for (R1's) fall 8/12/25, because (V3, CNA) pulled (R1) up (the wheelchair scale ramp) backwards resulting in (R1) facing forward on the way back down the slope. (R1) should have been pushed up the slope, weighed, and then exited the scale with the (V3, CNA) guiding his wheelchair backwards down the slope.o The facility policy Fall Guideline documents the following: Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth. To rehabilitate residents to their fullest potential of function.The same policy documents:The intent of this guideline is the ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146050 If continuation sheet Page 3 of 4 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 10/09/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Identification of hazards and risksEvaluation ImplementationMonitoringAnalysisPrior to the survey date of 10/9/25, the facility had taken the following action to correct the noncompliance:1. On August 12, 2025, the facility Compliance Assurance Committee developed a plan of correction for the 8/12/25 fall incident.2. On August 12,2025, the facility reviewed the procedure for weighing residents to ensure accuracy.3. On August 12, 2025, all facility staff were in-serviced on the safe and proper procedure for obtaining resident weights.4. Subsequent weights since 8/12/25 were observed and determined by the Quality Assurance process to have been safely completed per policy. Event ID: Facility ID: 146050 If continuation sheet Page 4 of 4