Arcadia Care Peoria Heights

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions during food service by ensuring sanitizing solutions were maintained at the required concentration and by maintaining potentially hazardous foods at required hot holding temperatures. This failure has the potential to affect all 79 residents who reside at this facilityFindings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/28/26 and signed by V1 (Administrator), documents 79 residents reside within the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the MDS (Minimum Data Set) Assessments for eight of 18 residents (R3, R5, R29, R37, R39, R48, R63, and R67) reviewed for MDS Accuracy in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, document, notify the physician, implement appropriate interventions, and update the care plan following identification of altered skin integrity for one (R71) of three residents reviewed for skin integrity.

Inspectors wroteBased on observation, interview, and record review the facility did not implement a physician-ordered hand protector to prevent contractures, failed to conduct a hand contracture assessment, and omitted the hand contracture from a resident's comprehensive care plan for one (R85) of three residents reviewed for splints and contractures in the sample list of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's bed was safe and in good repair for one (R24) of six residents reviewed for accidents in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to check gastrostomy tube placement prior to administering medications for one (R85) of one resident reviewed for gastrostomy tube in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nebulizer masks and tubing were dated and stored in a bag between uses, to post required oxygen safety signage, administer an inhaler per facility policy, and ensure oxygen tubing was labeled for three (R5, R67, R85) of three reviewed for respiratory care in a sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the daily resident census and direct care staff posting was posted in an area accessible to residents and visitors. This failure has the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one (R4) of four residents reviewed for abuse in a sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident equipment is kept clean for one resident (R1) of four residents reviewed for cleanliness of resident medical equipment, in a total sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean and homelike environment for four residents (R1, R2, R3) reviewed for clean and homelike rooms in a sample of four.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment to a facility acquired stage three pressure ulcer for one of three Residents (R4) reviewed for pressure ulcers in a sample of five.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication cart was locked and medications were secured. This has the potential to affect all 23 (R4, R6, R7, R15, R29, R30, R32, R34, R41, R43, R50, R53, R54, R63, R64, R67, R68, R70, R75, R88, R89, R95, and R97) residents who reside on the hallway where the incident occurred.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent resident to resident abuse for 2 residents (R24, R44) of 2 reviewed for abuse in a total sample of 40 residents. The Facility Reported Incident with finalization date of 12/31/25 documents on 12/25/25 at 5:55 PM V6, V8 (both Licensed Practical Nurses/LPN) and V9 (Certified Nursing Assistant/CNA) heard yelling coming from R44's room. When V6, V8, and V9 entered the room, R24 and R44 were hitting each other. The two residents were separated and assessed for injuries. R24 and R44 did not have any injuries. The Facility Reported Incident documents that R24 and R44 are both cognitively intact. On 1/6/26 at 10:12 AM R44 reported R24 was disrespectful to him and would not go into further detail. On 1/6/26 at 10:20 AM R24 reported R44 had his music loud and R24 asked R44 to turn it down. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement restorative therapies and interventions to prevent contracture for one (R64) of two residents reviewed for positioning and mobility in a sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to ensure hospice communication was coordinated and the required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R10) reviewed for hospice care management in a sample of 40 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene between glove changes and failed to wear a gown when performing gastronomy tube flush for 3 (R3, R4 and R53) of 3 residents reviewed for infection control in a sample of 40. The facility policy titled, Glove Use-Nursing, last approved 10/2024, documents not in its entirety, Hand hygiene will be performed after removing gloves. When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method of cleaning your hands in the healthcare setting. Soap and water are recommended for cleaning visibly dirty hands. The facility policy titled, Hand Hygiene/Handwashing, last approved 10/2024, documents not in its entirety, Hand hygiene means cleansing your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent resident-to-resident physical abuse and staff-to-resident verbal abuse for four of four residents (R1, R2, R3, R4) reviewed for abuse in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for one (R2) of three residents reviewed for abuse in a sample of four.

Inspectors wroteBased on record review and interview the facility failed to protect a resident from resident-to-resident verbal abuse for one of three residents (R3) reviewed for abuse in the sample of seven.

Inspectors wroteBased on interview and record review the facility failed to implement their Abuse Policy to immediately report an allegation of resident-to-resident abuse to the State Surveying Agency for two of three residents (R3 and R4) reviewed for reporting of abuse in the sample of seven.

Inspectors wroteBased on interview and record review the facility failed to implement their Abuse Policy to thoroughly investigate an allegation of resident-to-resident abuse for two of three residents (R3 and R4) reviewed for investigating abuse in the sample of seven.

Inspectors wroteBased on record review and interview the facility failed to report an allegation of potential mistreatment of a resident (R4) by a staff member to the state surveying agency after an allegation was made.

Inspectors wroteBased on interview and record review the facility failed to ensure a thorough investigation was conducted following a report of potential mistreatment of a resident (R4) for three residents reviewed for abuse in a sample of four.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure competent nursing care was provided for one of one resident who sustained a fall with a head injury (R1) in a sample of four.

Inspectors wroteBased on record review, observation and interview, the facility failed to label, or date refrigerated open and stored foods. The facility also failed to maintain a clean kitchen and work environment. This failure has the potential to affect all residents living in the facility except for R42 who does not receive oral intake.

Inspectors wroteBased on observation, interview, and record review the Facility failed to maintain comfortable and safe temperature levels for five of 24 Residents (R1, R10, R20, R26, and R75) reviewed for comfortable and homelike environment in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure transmission-based precautions and Enhanced Barrier Precautions were initiated and utilized per policy for two of 24 residents (R17, R286). The facility also failed to perform hand hygiene after indwelling urinary catheter care for one of three residents (R18) reviewed with indwelling urinary catheters in a sample of 33 residents.

Inspectors wroteBased on, observation, interview, and record review the facility failed to accurately document an upper extremity fracture and range of motion impairment in an MDS/Minimum Data Set for one of 24 residents (R82) reviewed for MDS accuracy in a sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to notify state mental health authority after a significant change in physical condition of two residents who have a mental disorder and failed to follow facility policy on Preadmission Screening and Annual Resident Review (PASARR) for two residents (R19, R59) of eight residents reviewed for PASARR in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement personalized care plans for two of 24 residents (R63, R77) reviewed for care plans in a sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to monitor and prevent weight loss for one of five residents (R77) reviewed for weight loss in the sample of 33 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for a severely cognitively impaired resident identified as an elopement risk for one of three residents (R1) reviewed for elopement. This failure resulted in R1 following ancillary staff out of the facility, taking public bus transportation, and wandering throughout the city unattended for greater than three hours. This past compliance occurred on 7/6/24.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of medications not available for one resident (R1) of three reviewed for notification in a sample of three.

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered medications were available for one resident (R1) of three reviewed for medications in a sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility was equipped with functional bathing facilities/shower rooms. This failure has the potential to affect all 90 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received showers as preferred instead of bed baths for five of six residents (R1, R3, R4, R5, R6) reviewed for accommodation of needs in the sample of sixteen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Certified Nursing Assistant staff were licensed and trained to perform resident haircuts. These failures had the potential to affect 12 of 12 residents (R1, R5, R7-R16) reviewed for competency of staff in the sample of 16.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 14 residents (R4) reviewed for elopement risk in the sample of 21. This failure resulted in a cognitively impaired resident (R4) exiting the facility without staff knowledge and being found at a local bus station approximately three miles away from the facility, in 34-degree Fahrenheit temperature and requiring Police transport back to the Facility. This failure resulted in an Immediate Jeopardy.

Inspectors wroteBased on observation, interview and record review the facility failed to allow the use of an electronic communication device/tablet for one of three Residents (R2) reviewed for communication in a sample of 21. This failure resulted in (R2) a deaf and aphasic resident experiencing agitation, crying and without a preferred source of communication.

Inspectors wroteBased on observation, interview, and record review that facility failed to staff a Licensed Administrator. This failure has the potential to affect all 85 Residents residing in the Facility.

Inspectors wroteBased on record review and interview the facility failed to perform and complete discharge planning for two (R3 and R7) of three Residents reviewed for Discharge Planning in a sample of 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean kitchen that includes ovens, ranges, mixers, beverage drip trays, grease trays, microwave oven, large containers steam table area. The facility failed to label and date food products for refrigerated foods and dry goods. The facility placed raw meat over ready to eat food or food ingredients and failed to put raw meat in leak proof pans. The facility failed to consistently check the level of Quaternary Ammonia in the sanitation buckets. The facility failed to keep food off the floor of the walk-in refrigerator and walk-in freezer. The facility failed to place thermometers inside the walk-in refrigerator and walk-in freezer. The facility failed to keep dished up food in the cooler. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the facility Ombudsman monthly of the facility transfers and failed to provide residents and resident representatives with a written notice of transfer. This failure has the potential to affect all 82 residents currently residing in the facility. Findings Include: 1. R3's (facility) Census List documents that R3 was hospitalized on [DATE]. R3's medical record does not contain documentation of written notice to R3 or R3's resident representative, of a transfer to the hospital. 2. R5's (facility) Census List documents that R5 was hospitalized on [DATE]. R5's medical record does not contain documentation of written notice to R5 or R5's resident representative, of a transfer to the hospital. 3. R17's (facility) Census List documents that R17 was hospitalized on [DATE], 9/3/23, 10/7/23 and 11/29/23. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital. This failure has the potential to affect all 82 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient dietary employees to serve the residents meals in the facility at the scheduled time. This has the potential to affect all 82 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to serve the correct amount of food according to the facility's written menu. This has the potential to affect all 82 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently record steam table food temperatures at each meal daily. The facility failed follow/attain recommendations for heating food in a microwave oven. The facility also failed provide residents with meals that were warm and palatable. This has the potential to affect all 82 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare enough food at meals to provide all the food items from the menu to all the residents. The facility substituted food items or omitted them. The facility failed to have a substitution log of foods that have been substituted from the menu. The facility failed to provide the residents with choices which included all the food items on the Always Available Menu. This failure has the potential to affect all 82 residents living at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve the correct, allowed food to the residents on a Low Fiber Diet and the Mechanical Soft Diet. This failure has the potential to affect 12 of 12 residents (R2, R4, R11, R18, R20, R23, R24, R28, R49, R51, R57, and R60) in a sample of 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent resident to resident physical and verbal abuse for 3 of 9 residents (R15, R37, R65) reviewed for Abuse in the sampled of 43.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of resident-to-resident physical abuse to the state agency and to the police for 3 of 9 residents (R15, R37, R65) reviewed for abuse in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to investigate and prevent further occurrence of an incident of resident-to-resident physical abuse for 3 of 9 residents (R15, R37, R65) reviewed for abuse in the sample of 42.

Inspectors wroteBased on record review and interview, the facility failed to follow a resident's advanced directive wishes in an emergency for one of one resident (R47) reviewed for Advanced Directives in the sample of 43.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record were accurate and without discrepancies for 1 of 18 residents (R47) reviewed for medical records in the sample of 43.

Inspectors wroteBased on observation and interview the facility failed to provide a clean and functioning sink for three residents (R5, R6 and R7) of three residents reviewed for functioning sinks in their rooms. Findings Include: On 12/28/23 at 1:30 PM the sink in room AA had rust colored water when water was run. The color did not clear when water was run for more than 30 seconds. On 12/28/23 at 1:31 PM V18 (Maintenance Director) stated I didn't know there was problem in here. I will address it today. On 12/28/23 R7 (Room AA occupant) stated I don't drink the water out of my room, it is gross. On 12/28/23 at 1:35 PM the sink in Room BB only ran lukewarm water on one side of the sink. On 12/28/23 V18 (Maintenance Director) stated Someone completely removed the cold-water valve; I am not sure why. On 12/28/23 R5 (Room CC occupant) refused to answer any questions. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide toenail care for one resident (R2) of three residents reviewed for foot care. Findings Include: R2's Podiatry Consent dated 4/5/23 documents (This Facility) offers monthly podiatry visits. I Accept was marked and signed by R2. On 12/28/23 at 1:00 PM R2's feet were very dry and misshapen. R2's left foot second toenail was thick and yellow and grown out enough to curl completely back on itself. R2's other toenails were thick and yellow. R2 stated that staff at the hospital had cut her toenails as best as they could. R2 stated she could not recall the last time her toenails were cut other than recently at the hospital. R2's Medical Record did not contain any documentation of any attempts to clip R2's toenails or to have R2 see the Podiatrist on his past two visits. [...]

Inspectors wroteBased on interview and record review, the facility failed to document the administration of the physician ordered medications for 1 of 3 residents (R2) reviewed for medication administration in the sample of 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right (R9) to be free from physical abuse by another resident (R8) out of four residents reviewed for abuse in a sample of 14. This failure resulted in R9 sustaining a fractured nose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were not wearing/using cell phone devices during their shift or when providing cares and were treating residents with respect. This has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow posted menu items. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to discard expired milk stored in the cooler. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right to not be recorded or photographed without consent for four residents (R10, R11, R13 and R14) out of eight residents reviewed for resident's rights in a sample of 14. Findings Include: The facility's Resident Rights policy dated 8/23/17 documents To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Exercise his or her rights. Be informed about what rights and responsibilities he or she has. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a means for residents to dry their hands after washing them for five residents (R1, R2, R3, R7 and R9) out of nine residents reviewed for supplies in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to provide showers to a resident who required assistance with bathing for one of three residents (R6) reviewed for activities of daily living in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician, provide treatments as ordered by the physician and failed to process a physician's order for one resident (R1) out of four residents reviewed for medication administration in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure a prescriber correctly transcribed an order for a resident's anti-seizure medications; failed to obtain follow-up physician orders after a resident's documented refusal of anti-seizure medications, and failed to ensure nurses accurately documented when an anti-seizure medication was given for one of four residents (R6) reviewed for medications in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician ordered laboratory tests for one of four residents (R6) reviewed for physician orders in the sample of 14.