Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Haven Of Arcola during CMS and state inspections, most recent first.
A resident with a history of falls, recent hip replacement, and moderate cognitive impairment was not safely assisted by a CNA during a weighing procedure. The CNA failed to follow proper protocol when maneuvering the resident's wheelchair on a sloped scale ramp, resulting in the resident falling forward out of the wheelchair and sustaining a lumbar vertebral fracture. Staff and the DON confirmed that the incident was due to improper handling during the transfer.
Two residents with mental health conditions experienced repeated breaches of privacy when one resident, who is cognitively intact but exhibits intrusive behaviors, entered others' rooms and opened privacy curtains during personal care. Staff confirmed ongoing difficulties in redirecting the resident, and the DON acknowledged these actions violated privacy rights.
Two residents with cognitive and behavioral health diagnoses were involved in repeated incidents of verbal abuse, including threats and derogatory language. Staff and administrator interviews confirmed that one resident verbally threatened and harassed another, and the facility did not effectively intervene to prevent or address the abuse, despite documented care plans outlining the risks and required interventions.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Three cognitively intact residents experienced a failure of dignity when one resident, who requires a wheelchair and supervision, was inappropriately touched by another resident in a common area. The incident was witnessed by another resident and confirmed by an LPN. The care plan for the affected resident did not address behaviors related to sexual conduct, and both residents involved required constant supervision on a locked psychiatric unit.
A resident with a history of mental health issues verbally threatened and intimidated other residents, causing fear and distress. Despite staff awareness, the facility failed to prevent these incidents, resulting in a deficiency in protecting residents from verbal abuse.
The facility failed to report verbal abuse incidents involving three residents to the Abuse Coordinator, as required by policy. An LPN witnessed a resident threatening another during supper but did not report it, assuming the administrator would be informed. A Social Service Assistant was aware of another altercation but did not report it separately. The administrator confirmed staff did not follow the facility's abuse policy.
The facility did not ensure RN coverage for eight consecutive hours daily, as required. On several occasions, no RN was scheduled, and on one occasion, an RN was present for only four hours. The administrator acknowledged the staffing issue, which affected 69 residents in the SNF-certified facility.
An LPN failed to perform hand hygiene during medication administration for multiple residents, leading to potential cross-contamination. Despite facility policy requiring handwashing or the use of alcohol-based hand rub (ABHR) between residents, the LPN did not adhere to these guidelines, touching various surfaces without using ABHR. The LPN acknowledged the oversight, and the Regional DON confirmed the necessity of hand hygiene between residents.
A facility failed to obtain a new Level 2 PASRR for a resident with Paranoid Schizophrenia after the initial evaluation expired. The resident required specialized mental health services, but the facility lacked documentation of a more recent assessment, and the screening agency had no records of an updated evaluation.
A facility failed to complete a baseline care plan within 48 hours for a resident admitted with multiple medical conditions, including a wedge compression fracture and dementia. The resident's care plan lacked necessary focus areas, goals, and interventions before the resident experienced a fall. Staff interviews revealed a lack of awareness about the required timeframe for completing baseline care plans.
A resident experienced falls and was supposed to have an alarm on her wheelchair as a post-fall intervention. However, during an observation, it was found that the alarm was missing, with only the power cord present. An LPN confirmed the absence of the alarm, indicating a failure to implement the care plan.
A resident with a history of movement disorder and dementia was found to have a loose bed side rail, which was used for mobility and transfers. The rail was observed to be excessively loose, with a gap exceeding FDA safety guidelines, and the resident expressed concern about its condition. An LPN confirmed the need for replacement due to the safety risk.
A resident with severe cognitive impairment hit another resident during breakfast after the latter grabbed the former's oatmeal. The incident was witnessed by staff and another resident, confirming the action was intentional. The resident who was hit had memory loss, and no injury was noted. The facility's policy affirms residents' rights to be free from abuse, yet this incident affected three residents reviewed for abuse.
A facility failed to report an alleged abuse incident where a resident reported feeling afraid after another resident grabbed their wrist. Despite the resident informing a CNA, the incident was not reported to the administrator as required by the facility's Abuse Prevention Program.
A resident was mistakenly given another resident's medications due to a room change that was not properly communicated, resulting in an emergency room visit for an accidental overdose. The facility's policy requiring verification of resident identity was not followed, leading to the administration of medications not prescribed for the resident.
The facility failed to document interventions for five residents reviewed for abuse, despite having an abuse prevention policy. Interventions such as separating residents and relocating activity carts were identified but not recorded in medical records, as confirmed by the administrator.
Failure to Safely Assist Resident During Weighing Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with a high risk for falls, significant medical history including a recent right hip replacement, spinal stenosis, osteoarthritis, and moderate cognitive impairment, was not safely assisted during a routine weighing procedure. The resident, who required substantial to maximum assistance with transfers and used a manual wheelchair, was being weighed on a platform scale with a sloped ramp. The Certified Nursing Assistant (CNA) assisting the resident backed the wheelchair onto the scale and, after weighing, pushed the wheelchair forward down the ramp, allowing the resident to face forward. As a result, the resident fell forward out of the wheelchair and sustained a vertebral fracture. The incident was witnessed, and it was documented that the resident hit his head and complained of pain on the right side. The resident was on blood thinners and had a history of falls, including a recent hip fracture at home that led to his admission for rehabilitation. The facility's own staff and the resident confirmed that the usual and safe practice was to push the wheelchair up the ramp facing forward and to pull the resident backwards down the ramp to prevent forward falls. However, on this occasion, the CNA did not follow this protocol, resulting in the resident's fall and injury. Interviews and record reviews revealed that the resident had experienced other falls in the facility, some due to self-transferring, but the fall during the weighing procedure was attributed to staff error. The facility's Director of Nursing and other staff acknowledged that the improper handling of the wheelchair on the scale ramp directly led to the resident's fall and subsequent lumbar fracture. The facility's fall prevention policy emphasized the need for an environment free from hazards and appropriate supervision, which was not adhered to during this incident.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to protect the privacy and confidentiality rights of its residents, specifically affecting two individuals with significant mental health diagnoses. One resident, who is cognitively intact but exhibits behaviors such as attention seeking, repetitive questioning, invading personal space, and inappropriate comments, repeatedly entered other residents' rooms and personal spaces, with documentation showing 17 such incidents in the past 30 days. This resident was also noted to open privacy curtains while staff were providing personal care to another resident, thereby exposing that resident during vulnerable moments. Staff interviews confirmed that the resident's behavior was ongoing and difficult to redirect, with multiple staff members acknowledging the repeated invasions of privacy. The Director of Nursing was unaware of the specific incidents involving the privacy curtain but confirmed that such actions constitute a violation of the affected resident's right to privacy. The facility's own policy emphasizes the importance of protecting resident rights, including privacy and confidentiality, but staff interventions were insufficient to prevent these breaches.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from verbal abuse, as evidenced by multiple incidents involving two residents. One resident, diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia, exhibited behaviors such as attention seeking, repetitive questions, invading personal space, and making inappropriate comments. Another resident, diagnosed with Bipolar Disease, Anxiety, and Mild Cognitive Impairment, displayed behaviors including agitation, verbal outbursts, mocking, yelling, and making false allegations. Staff interviews confirmed that the second resident verbally threatened the first resident, including yelling expletives and making threats of physical harm. Staff also reported that the second resident frequently told the first resident to "shut up and go away." The care plans for both residents documented their behavioral challenges and the need for staff intervention to protect the rights and safety of others. Despite these documented needs, the facility did not prevent or adequately address the verbal abuse occurring between the residents. The administrator confirmed that the threats made constituted verbal abuse and acknowledged that the first resident's behaviors placed her at risk for such abuse. The deficiency was identified through interviews and record reviews, which demonstrated a failure to uphold the facility's abuse policy and protect residents from verbal abuse.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Resident Dignity During Inappropriate Contact Incident
Penalty
Summary
The facility failed to ensure resident dignity for three cognitively intact residents who were reviewed for dignity concerns. One resident, who requires a wheelchair for mobility and supervision with daily activities, reported that another resident approached her in a common area, rubbed her upper leg, and attempted to touch her perineal area. The incident was witnessed by another resident, who confirmed that the resident in question placed his hand on the inside of the first resident's lower thigh and moved it upwards, prompting the first resident to move away in her wheelchair. The staff member interviewed confirmed the sequence of events and stated that the resident who initiated the contact was sent to the emergency room for evaluation due to his behaviors. The care plan for the resident who was touched did not include any focus area, goal, or interventions related to behaviors of consensual sexual behavior with male peers prior to the incident. Both residents involved were documented as cognitively intact but required constant supervision and resided on a locked psychiatric unit. The facility's policy states that residents have the right to be treated with dignity and respect, but the lack of appropriate care planning and supervision led to a situation where a resident's dignity was not maintained.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by incidents involving a resident, R1, who verbally threatened and intimidated other residents, R2 and R7. R1, who has a history of depression, bipolar disorder, and other medical conditions, was involved in multiple altercations where he yelled and cursed at fellow residents. On one occasion, R1 threatened to kill everyone in the dining room, causing fear among residents and staff. R2, who was present during the incident, reported feeling scared and noted that R1's behavior was aggressive and intimidating. Another incident involved R1 yelling at R7 to vacate a chair in the community dayroom, using threatening language. R7, who has schizophrenia and bipolar disorder, expressed feeling scared by R1's aggressive demeanor. The facility's staff, including LPNs and the administrator, were aware of R1's outbursts but failed to prevent these incidents or adequately protect the residents from verbal abuse. The facility's administrator acknowledged that R1's behavior was inappropriate and that the incidents were not initially recognized as abusive. The administrator later confirmed that R1's actions constituted verbal abuse towards R2 and R7. Despite the awareness of R1's behavior, the facility did not take immediate action to prevent further incidents, resulting in a deficiency in protecting residents from abuse.
Failure to Report Verbal Abuse Incidents
Penalty
Summary
The facility failed to report allegations of verbal abuse involving three residents to the Abuse Coordinator, as required by their policy. The policy mandates that employees report any incident, allegation, or suspicion of abuse immediately to the administrator or a designated individual in their absence. However, the facility did not document the reporting of a verbal altercation between two residents on December 23, 2024, nor did they report a separate incident involving another resident on December 21, 2024, to the State Agency. Interviews with staff and residents revealed that these incidents were not communicated to the appropriate authorities, as required by the facility's abuse prevention policy. In one incident, a resident was verbally threatened by another resident during supper, causing fear among the residents present. A Licensed Practical Nurse (LPN) witnessed the incident but did not report it, assuming the administrator would have been informed through other means. In another incident, a Social Service Assistant (SSA) was aware of a verbal altercation between two residents but did not report it separately, believing it would be included in the investigation of other incidents involving the same resident. The administrator confirmed that staff did not adhere to the facility's policy by failing to report these incidents, highlighting a breakdown in communication and adherence to established procedures.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that on specific dates in October and November 2024, there was no RN scheduled to work for the required hours. Specifically, on 11/2/24, 11/5/24, and 10/29/24, no RN was scheduled, and on 10/27/24, an RN was only present for four hours. The facility's administrator acknowledged the absence of an RN on these dates during a review of the Nurses Schedules. The administrator admitted awareness of the staffing issue and anticipated receiving a citation for this deficiency. The facility's Form 802 Resident Matrix indicated that 69 residents were residing in the facility at the time of the survey, and all 100 beds in the facility were certified as a Skilled Nursing Facility (SNF).
Failure to Prevent Cross-Contamination During Medication Administration
Penalty
Summary
The facility failed to prevent cross-contamination during medication administration for four residents. The deficiency was observed when a Licensed Practical Nurse (LPN) did not perform hand hygiene before and between administering medications to multiple residents. The LPN was seen touching various potentially contaminated surfaces, such as medication cards, the medication cart, computer screens, medicine cups, water cups, water pitchers, resident doors, privacy curtains, and bedside tables, without using alcohol-based hand rub (ABHR) or washing hands. The facility's policy on medication administration, revised in 2017, requires appropriate handwashing or the use of ABHR throughout the medication pass, especially before and after medication administration and after touching potentially contaminated objects. Despite having a bottle of ABHR on the medication cart, the LPN did not adhere to these guidelines. The LPN acknowledged the failure to use hand hygiene and recognized the risk of spreading bacteria between residents. The Regional Director of Nursing confirmed that hand hygiene should be performed between every resident during medication administration.
Failure to Update Level 2 PASRR for Resident with Mental Health Needs
Penalty
Summary
The facility failed to obtain a new Level 2 PASRR (Preadmission Screening and Resident Review) for a resident, identified as R28, to evaluate the need for specialized mental health services after the expiration of the initial Level 2 evaluation. R28 had a history of inpatient mental health hospitalizations and was diagnosed with Paranoid Schizophrenia, experiencing symptoms such as delusions, irritability, and difficulty remaining on tasks. The initial Level 2 PASRR, dated 8/17/2015, determined that R28 required specialized services, including mental health rehabilitation, illness self-management, and community re-integration activities, and was valid for 90 days, expiring on 11/22/2015. However, as of 11/7/24, the facility's Business Office Manager and Social Services Director confirmed they did not have any documentation of a more recent Level 2 PASRR, and the screening agency also had no records of an updated evaluation.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident, identified as R270, who was admitted with medical diagnoses including a wedge compression fracture of the T9-T10 vertebrae, dementia, and hypertension. Upon admission, the resident was alert and oriented to person only. The resident's care plan did not include a focus area, goal, or interventions prior to a fall that occurred on November 4, 2024. The baseline care plan was not initiated until November 6, 2024, which was after the fall incident. Interviews with facility staff revealed a lack of awareness regarding the timeframe for completing a baseline care plan. The Care Plan Coordinator, a Licensed Practical Nurse, stated that the baseline care plan is typically completed within the first week of admission and was unaware of the requirement to complete it within 48 hours. The facility administrator confirmed that the baseline care plan should be completed within 48 hours and acknowledged that the initial assessment does not include goals or interventions for staff to use in providing care.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care planned post-fall interventions for fall prevention for one resident. The resident, identified as R59, was observed seated in her room in a wheelchair with a power cord for a personal alarm hanging from the back, but the actual alarming module was missing. R59's care plan, which was undated, documented that she experienced falls on two occasions, and the intervention after the fall on June 9 was to provide an alarm on her wheelchair. Nursing progress notes from June 9 and June 10 documented that R59 was found on the floor sitting on her buttocks with her wheelchair next to her. On November 6, a Licensed Practical Nurse and Care Plan Coordinator confirmed that R59 was supposed to have an alarm on her bed and wheelchair, but only the power cord was present on the wheelchair, indicating a failure to implement the planned intervention.
Unsafe Bed Side Rail Condition for a Resident
Penalty
Summary
The facility failed to maintain a resident's bed side rail in a safe condition, affecting one resident (R12) out of five reviewed for bed side rails. R12 has a medical history that includes Extrapyramidal and Movement Disorder, Left Knee Valgus Deformity, and Dementia, with impaired range of motion in both lower extremities. R12's care plan indicates the use of a bed side rail for mobility, and staff are encouraged to promote R12's independence by using the side rail. However, observations revealed that R12's half-length right side bed rail was loose and leaning outward, with a significant gap between the rail and the mattress, exceeding the maximum safe spacing recommended by the FDA to reduce the risk of entrapment. On two separate occasions, the bed rail was found to be excessively loose, moving back and forth and pivoting towards the floor when touched. R12 expressed concern about the loose rail, stating it had been in this condition for a long time and was worried about it. A Licensed Practical Nurse (V11) confirmed the rail's condition and acknowledged it needed replacement, especially since R12 uses it for transfers. The deficiency was identified through observation, interview, and record review, highlighting the facility's failure to ensure the safety of the bed side rail system for R12.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by another resident. The incident involved a resident with severe cognitive impairment who hit another resident on the face after the latter grabbed the former's oatmeal during breakfast. This incident was witnessed by staff and another resident, and it was confirmed that the action was intentional. The resident who was hit had short and long-term memory loss, and there was no injury or redness noted after the incident. The facility's investigative file included interviews with staff and residents who witnessed the event. It was noted that the resident who was hit had a history of grabbing other residents' food and drinks, which led to the altercation. The facility's Abuse Prevention Policy affirms residents' rights to be free from abuse, including physical abuse, and defines abuse as a willful act. Despite the policy, the incident occurred, affecting three residents reviewed for abuse in the sample list.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the administrator, as required by their Abuse Prevention Program. A resident, identified as R3, reported that another resident, R2, had grabbed R3's wrist, causing R3 to feel afraid. This incident occurred when R2 entered R3's room uninvited, and R3 asked R2 to leave. R3's call light was activated, and staff responded by redirecting R2 out of the room. R3 informed a Certified Nursing Assistant (CNA), identified as V8, about the incident, but V8 denied being told that R2 had grabbed R3. Another CNA, identified as V3, confirmed that R3 had mentioned the wrist-grabbing incident and reported it to a nurse, although V3 could not recall which nurse. The administrator, identified as V1, stated that no abuse allegations involving R2 and R3 had been reported to them until the surveyor's inquiry. The facility's policy requires employees to immediately report any potential or alleged mistreatment, exploitation, neglect, and abuse to a supervisor and the administrator, which did not occur in this case.
Medication Administration Error Due to Incorrect Resident Identification
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not correctly identifying a resident prior to medication administration. This incident involved a resident who was mistakenly given another resident's medications due to a room change that was not properly communicated. The Director of Nursing was training a new Licensed Practical Nurse, who administered the wrong medications to the resident because the nameplate on the door had not been updated to reflect the room change. The resident who received the incorrect medications was admitted to the facility with multiple medical conditions, including Congestive Heart Failure, Atrial Fibrillation, and Type 2 Diabetes. The error resulted in the resident being sent to the emergency room for treatment of an accidental medication overdose. The resident received intravenous fluids, Vitamin K to counteract the effects of Coumadin, and other treatments. The facility's Medication Administration Policy, which requires verification of the resident's identity using two methods, was not followed. The medications administered included Coumadin, Trazadone, Lyrica, Oxcarbazepine, and Atorvastatin, none of which were prescribed for the affected resident. This error was compounded by the fact that the resident was already on a different anticoagulant and antidepressant, leading to potentially harmful duplicative and additive effects.
Failure to Document Abuse Prevention Interventions
Penalty
Summary
The facility failed to operationalize its abuse prevention policy by not documenting identified interventions for five residents reviewed for abuse. The facility's Abuse Prevention Program Policy, dated 11/28/16, emphasizes the importance of preventing abuse, neglect, and exploitation of residents. However, the medical records of residents R2, R3, R4, R5, and R6 lacked documentation of interventions to address behaviors with other residents, which is a critical component of the care planning process aimed at reducing the chances of mistreatment, neglect, and abuse. During interviews, the administrator confirmed that specific interventions were identified but not documented. For instance, after a resident-to-resident abuse incident involving R2 and R6, the intervention was to keep them separated and prevent R2 from asking for hugs, but this was not recorded. Similarly, after a staff-to-resident abuse incident involving R3, the intervention was to remove the snack cart from reach without assistance, which was also undocumented. Additionally, after another resident-to-resident abuse incident involving R4 and R5, the intervention was to relocate the activity cart to a less crowded area, but this too was not documented. The administrator acknowledged that all interventions should have been documented in the residents' medical records or care plans to ensure staff awareness and implementation to prevent further incidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Arcola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Haven Of Tuscola | 7.5 mi | — | 3 | 0 |
| Arthur Home, The | 9.6 mi | — | 0 | 0 |
| Hilltop Skilled Nsg & Rehab | 10.5 mi | — | 4 | 0 |
| Odd Fellow-rebekah Home | 13.8 mi | — | 18 | 0 |
| Charleston Rehab And Nursing | 14.7 mi | — | 11 | 0 |
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