Arcadia Care Rock Island

Inspectors wroteBased on interview and record review, the facility failed to perform Cardiopulmonary Resuscitation (CPR) in a manner to provide adequate oxygenation to a resident (R2). This applies to 1 of 3 residents reviewed for change in condition in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to assess a non-removable lower extremity cast for one of one residents (R1) reviewed for casts in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was safely transferred with a full mechanical lift according to their plan of care for 1 of 3 residents reviewed for safety/supervision in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately supervise a known wandering resident (R1), failed to have systems in place to monitor the front door alarms after hours and failed to have interventions in place for a known faulty (electronic wandering device) door alarm system for one (R1) of twenty-two residents reviewed for elopement/wandering. These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of Vascular Dementia, eloping from the facility to a grassy area out front of the building, by a curb, close to a busy road attempting to get on a city bus. This failure has the potential to affect all seven (R4-R10) Elopement Risk residents who reside off the secured floor in the facility. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review the facility failed to employ a full time qualified Social Worker in a facility licensed for 177 beds. This has the potential to affect all 70 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to treat a resident (R1) with dignity. This applies to 1 of 3 residents reviewed for dignity in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and keep a resident (R1) informed of the status of a grievance. This applies to 1 of 3 residents reviewed for grievances in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement dietician recommendations for a resident (R1) receiving tube feedings. This applies to 1 of 1 residents reviewed for tube feedings in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physicians orders for a resident (R1) with a G-tube (Gastrostomy tube). This applies to 1 of 1 residents reviewed for G-tubes in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to ensure a resident was free from physical abuse resulting in potential injury for 2 of 3 residents (R2, R11) reviewed for abuse in the sample of 12. The immediate jeopardy began on 6/11/25 at 6:50 PM when R1 returned to the facility from being evaluated at the acute care hospital after grabbing R11 by the neck. R1's care plan was updated to include 1:1 supervision on 6/11/25. No evidence was found of R1 being on 1:1 supervision until 6/18/25 after the second incident when R1 pushed R2 to the floor. V1 (Administrator) was notified of the Immediate Jeopardy on 7/18/25 at 11:23 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to assess respiratory status for one resident (R3) who displayed respiratory changes of three residents reviewed for change of condition in the sample of five. This deficient practice resulted in a delay in the assessment of the resident's respiratory status and subsequent need for additional medical intervention.

Inspectors wroteBased on record review and interview the facility failed to provide the resident and the resident's representative the facility's written bed hold policy within 24 hours of transfer for two of two residents (R50 and R60) reviewed for bed holds in a total sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan to include a resting hand splint for one (65) of one resident reviewed for devices in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan to remove checking an AV/Arteriovenous fistula site; failed to include who to contact for emergencies/complications, failed to include a target weight; failed to have an assessment and care of the central dialysis port; and failed to include resident specific dialysis orders for two (R13 and R50) of 18 residents reviewed for care plan revisions in a sample of 31.

Inspectors wroteBased on interview and record review the facility failed to follow physician's orders to flush an indwelling urinary catheter and failed to identify and document changes in urine output/characteristics for one resident (R76) of four residents reviewed for urinary catheters in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a resting hand splint for one (R65) of one resident reviewed for devices in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have specific dialysis orders related to the type of dialyzer, flow rate, and length of time; target weights; and care of the dialysis port for two (R13 and R50) of two residents reviewed for dialysis in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to have pneumonia vaccination records documented in the resident record and failed to offer pneumonia vaccinations for two (R13 and R65) of five residents reviewed for pneumonia vaccinations in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to have Covid-19 vaccination records documented in the resident record and failed to offer Covid-19 vaccinations for three (R13, R61 and R65) of five residents reviewed for Covid-19 vaccinations in a sample of 31.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator for one of six residents (R4) reviewed for abuse in the sample of six.

Inspectors wroteBased on observation, interview and record review the facility failed to safely operate a mechanical lift transfer for one resident (R5) and failed to transfer one resident (R6) via mechanical lift as identified in the plan of care of three residents reviewed for mechanical lift transfers in the sample of seven.

Inspectors wroteBased on record review and interviews the facility failed to provide staff supervision to prevent a resident-to-resident altercation for two of three (R1) and (R2) residents reviewed for resident altercations in a sample of three. Findings Include: The facility abuse policy, named Facility Abuse Prevention Guidance, revised October 2022, documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. Purpose of this guidance is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment of residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label and store daily medications. This failure has the potential to affect all 24 residents (R2, R8, R9, R16, R17, R21, R23, R26, R31, R33, R34, R36, R41, R42, R50, R52, R55, R59, R66, R71, R73, R178, R179 and R227 )residing on the facility Second Floor.

Inspectors wroteBased on record review and interview the facility failed to perform a PASARR Level I or II for one of three residents (R10) reviewed for PASARR (Preadmission Screening and Resident Review) screening in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to warrant the increase in an antipsychotic following a GDR (Gradual Dose Reduction for one of two (R38) residents reviewed for antipsychotics in the sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility to provide assistive devices during meals to ensure a resident maintains or improves their ability to eat or drink independently for one of one resident (R5) reviewed for assistive devices in the sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to cleanse the skin to be injected with alcohol and failed to wear gloves while administering an injection for two residents (R23 and R42) of five residents that were observed during medication pass, in a total sample of 32. Findings Include: The facility policy, Insulin Administration Procedure, dated (revised) 05/23 directs staff, To assure the proper administration of Insulin to residents. Wash hands and wear gloves. Clean the area of skin to be injected with alcohol. Allow the alcohol to evaporate completely before injecting insulin. Inject Insulin into the subcutaneous tissue at a 90- degree angle. Dispose of used syringe and needles in the Sharp's container. Remove gloves and wash hands. 1.) R23's current Physician Order Sheet dated July 2023 includes the following diagnosis: Type 2 Diabetes Mellitus. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to identify specific target behaviors for four residents (R9, R12, R32, R44) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 31. The facility also failed to provide a consent for antipsychotic medication administration for two residents (R12, R44) and failed to ensure an as needed psychotropic medication was limited to fourteen days for one resident (R42) of five residents reviewed for psychotropic medications in a total sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to report a facial bruise of unknown origin to the State Agency for one resident (R44) of one resident reviewed for abuse in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately input hospice services in the MDS (minimum data set) assessment for one (R41) of 18 residents reviewed for MDS accuracy in the sample of 31.