Arc at Dwight

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 89 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to notify residents of potential financial liability when Medicare covered services ended for three of three residents (R38, R67, and R97) reviewed for Medicare notification requirements on the sample list of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by another resident. This failure affected two (R23 and R71) of three residents reviewed for abuse in the sample list of 36 residents.

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to be free from resident-to-resident verbal abuse. This failure affected three of four residents (R1, R2, R3) reviewed for abuse on the sample list of four. Findings Include: The facility's Abuse and Prevention Reporting - Illinois Policy dated March 2026 documents each resident has the right to be free from abuse including but not limited to verbal abuse. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families or within their hearing distance. 1. R3's Medical Diagnoses list dated April 2026 documents R3 is diagnosed with Major Depressive Disorder. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact and had verbal behavioral symptoms at four to six times during the review period. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident's (R14) right to be free from sexual abuse by another resident (R15), protect a resident's (R12) right to be free from verbal/mental abuse by another resident (R11), protect a resident's (R8) right to be free from physical abuse by another resident (R3), and protect residents' (R2, R3) right to be free from physical abuse by another resident (R3, R2). These failures affect seven residents (R2, R3, R8, R11, R12, R14, R15) of 12 residents reviewed for abuse in the sample list of 15.

Inspectors wroteBased on observation, interview and record review the facility failed to report allegations of resident-to-resident abuse to the administrator for four (R9, R10, R11, R12) of 12 residents reviewed for abuse in the sample list of 15.

Inspectors wroteBased on interview and record review the facility failed to implement measures to prevent further abuse during an abuse investigation for three (R2, R3, R8) of 12 residents reviewed for abuse in the sample list of 15.

Inspectors wroteBased on interview and record review the facility failed to develop a care plan with problem, goals, and interventions to address behaviors of disrobing for one (R14) of 12 residents reviewed for abuse in the sample list of 15.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall interventions and thoroughly investigate falls for two (R5, R6) of three residents reviewed for falls in the sample list of 15.

Inspectors wroteBased on interview and record review, the facility failed to perform a mechanical lift transfer safely for one (R1) of three residents reviewed for transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clinically qualified director of food and nutrition services. This failure has the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide certified food handlers for the meal service and food preparation operations. This failure has the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meal service in the posted service times. This failure affects six residents (R14, R15, R21, R47, R59, and R195) of six residents who received meal trays in their rooms, on the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pharmacy/hormone replacement medication guidance, for one of eight residents (R32) reviewed during medication administration observation. The facility had three medication errors out of 30 opportunities resulting in a 10 percent medication error rate.

Inspectors wroteBased on interview and record review, the facility failed to protect a residents (R2) right to be free from inappropriate touching by another resident (R1), for 1 (R2) out of three residents reviewed for abuse in the sample of five residents.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of sexual abuse to the state survey agency for two of three residents (R1, R2) reviewed for sexual abuse in the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the services of a clinically qualified director of food and nutrition services. This failure has the potential to affect all 77 residents residing in the facility, with R18 being one exception. Findings Include: On 4/2/24 at 9:44 AM, V5 Dietary Manager stated, I am the Dietary Manager. I started here as the manager in 2019. I have an FSM (Food Service Manager, cooking sanitation certificate) certificate. The FSM took one day to get. It was a one day course of study and take a test. I also have a CFM (Certified Food Manager, cooking sanitation certificate) certificate which is basically the same course of study and take a test that also took one day. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to honor residents' right to dignity during dining by daily serving of meals on disposable dishware and by standing over residents while providing feeding assistance. This failure affects seven residents (R8, R13, R15, R17, R22, R37, and R61) out of 18 reviewed for dignity on the sample list of 47. Findings Include: 1. On 4/2/24 at 12:10 PM, V3 Dietary Manager stated, We are serving the foam plates due to the dishwasher being broken. The dishwasher has been broken since February (2024), it first started leaking and it got worse, and then it finally quit. The server today started serving on regular plates then realized she intended to use foam plates for everybody. On 4/3/24 at 12:42 PM, R37 stated, I don't like the foam plates. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe and comfortable water temperatures in resident hand sinks on the facility's C Hall (300 Hall). This failure affects 14 residents (R5, R10, R11, R13, R26, R31, R33, R38, R46, R52, R57, R58, R59, and R61) out of 18 reviewed for accident hazards on the sample list of 47. Findings Include: On 4/2/24 at 2:15 PM, the water temperature in the hand sink in room [ROOM NUMBER] had a stinging sensation to the hand. The water temperature in this same sink measured 119.4 degrees Fahrenheit (F) with an Illinois Department of Public Health Digital Automatic Calibration thermometer. room [ROOM NUMBER] had a hand sink water temperature of 115.3 F. room [ROOM NUMBER] had a hand sink water temperature measuring 122.3 F. room [ROOM NUMBER] hand sink water temperature measured 114.6 F. [...]