Inspection visit
Health inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0565
Honor the resident's right to organize and participate in resident/family groups in the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure residents know who the
Grievance Officer is, failed to provide a private area for resident council meetings, and failed to provide a
response, action or rationale for Resident Council concerns for five (R17, R22, R34, R41, and R65) of five
residents reviewed during Resident Council meeting in the sample of 31.
Residents Affected - Some
Findings include:
The facility's Grievance policy and procedure, revised 9/25/17, documents Purpose: To ensure prompt
resolution of all grievances with respect to care and treatment which has been furnished as well as that
which has not been furnished, the behavior of staff and of other residents, and other concerns regarding
their status at this campus. Contact information of independent entities with whom grievances may be filed,
that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency, and State
Long-Term Care Ombudsman program or protection and advocacy system shall be posted in prominent
locations throughout the facility and/or provided to residents individually. Grievances may be filed orally
(meaning spoken), in writing, or anonymously. Grievances may also be filed anonymously through the
Corporate Compliance Hotline. Contact information for the Corporate Compliance Hotline shall be posted in
prominent locations throughout the facility. All written grievances shall include: The date the grievance was
received; A summary statement of the grievance; Department assigned to investigate; Steps taken to
investigate the grievance; Summary of the pertinent findings or conclusions regarding the concern (s);
Statement as to whether the grievance was confirmed or not confirmed; Corrective action taken or to be
taken by the facility as a result of the grievance, including measures taken to prevent further potential
violations of any resident right while the alleged violation is being investigated; and the date the written
decision was issued to the resident or the complainant.
The facility's undated Residents' Rights for People in Long-Term Care Facilities documents You have the
right to participate in the resident council and You have the right to complain to your facility and to get a
prompt response.
The facility's Resident Family Handbook, dated 10/2013 documents You have the right to participate with
other residents in the Resident Council. The facility must respond to concerns raised by the council. You
have the right to present grievances to the facility and to get a prompt response. This same Handbook
documents The purpose of the Resident Council is to protect and preserve residents' rights and to afford
residents a forum to voice and discuss grievances and other problems and to participate in the resolution of
these concerns. The Council is encouraged to make recommendations regarding facility operations, quality
of life, resident care issues and to assist in the planning of outings, parties and special events and other
activity programming. All suggestions, complaints or views of the Resident Council presented in writing to
the Administrator, Social Service Director or other
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
145248
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0565
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
facility staff will be reviewed and acted upon. The Facilities Concern/Suggestion form will be used to
document all concerns and complaints. The Administrator will respond to all written recommendations and
complaints of the Council in writing and in accordance with the Facility grievance policy.
On 4/10/24 at 10:00 am, a Resident group meeting was held with R17, R22, R34, R41, and R65 in the
dining room. Two empty food carts, wrapped in plastic were placed at the entrance to the dining area as
there were no doors to close to provide privacy for the residents to speak. During this meeting, staff and
resident conversations could be heard from the opposite side of the food carts, outside of dining area. R17,
R22, R34, R41, and R65 stated it is always loud during their Resident Council meetings and V19
Ombudsman confirmed and nodded head yes in agreement of loud noise level during the Resident Council
meetings. R17, R22, R34, R41, and R65 stated they do not know who the facility's Grievance Coordinator
is, do not know the location of the facility's required postings, and tell the facility what the issues and
concerns are but never get a response from their concerns and have to keep complaining about it.
The monthly Resident Council Minutes dated April 2023 through April 2024 reviewed and do not include
follow up on resident complaints or concerns from the prior month.
On 4/9/24 and 4/10/24 from 8:00 am to 4:30 pm, and on 4/11/24 from 8:00 am to 11:30 am, the only facility
required posting was for Ombudsman office information.
On 4/12/24 at 2:00 pm, V1 Administrator stated resident grievances are completed with the resident who
reports the grievance and does not always address all of the resident council members. V1 Administrator
stated she will ensure that Resident Council grievances are shared with the Council members and will
make sure that everyone knows that V15 SSD/Social Service Director is the Grievance Officer. V1
Administrator confirmed the dining room is where Resident Council meetings are held and there is no door
to close off the room. V1 Administrator stated she will look into having the Resident Council meetings in
another area, possibly in the Conference room instead of the dining room. V1 Administrator also stated she
has now posted all the required postings and the name of the Grievance Officer for the residents review
and will ensure they remain where the residents can locate them.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 2 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0575
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy
groups and a statement that the resident may file a complaint with the State Survey Agency.
Based on observation, interview, and record review the facility failed to post required State and Federal
postings for Long-Term Care Facility Resident use. This failure has the potential to affect all 70 residents
residing in the facility.
Findings include:
The facility Resident and Family Handbook dated 10/2013 and the facility's undated Residents' Rights for
People in Long-Term Care Facilities policy and procedures document the Residents Rights with contacting
outside organizations and advocates including the Ombudsman, Equip for Equality, State Agency, Medicaid
Fraud Control Unit, and Identified Offender Information.
On 4/9/24 and 4/10/24 from 8:00 am to 4:30 pm, and on 4/11/24 from 8:00 am to 11:30 am, the only facility
required posting was for the Ombudsman office. There were no other required postings noted.
On 4/10/24 at 11:25 am, V1 Administrator confirmed there are no postings other than the Ombudsman's
information and stated, she has never had the required postings put up in any of her facilities and has only
ever put the Ombudsman's poster. V1 Administrator stated she will check with V14 Activity Director who has
been at the facility a long time.
On 4/10/24 at 11:30 am, V14 Activity Director stated, the postings used to be up on the wall in the glass
cabinet, but the previous Housekeeping Supervisor pulled them all down just prior to the start of the
remodeling here which I think they started that in November last year. V14 Activity Director stated she will
see if she can find them.
The Resident Council Minutes, dated 9/9/23, documents Residents were reminded that the remodel is in
full swing, and they will start doing the halls and the nurses' desks.
On 4/10/24 at 1:30 pm, V14 Activity Director stated she could not find the postings, so they printed off new
ones and hung them on the glass window in the front of the facility.
The Long-Term Care Facility Application for Medicare and Medicaid form, dated 4/9/24, documents there
are 70 residents currently residing in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 3 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on interview and record review, the facility failed to notify in writing, and maintain a copy in the
medical record notification to the Ombudsman and resident/resident representatives of residents that were
reviewed for notices before transfers. This failure has the potential to affect all 70 Residents residing in the
Facility.
Findings include:
Facility Bed Hold and Return to Facility policy, revised 9/17/17, documents To ensure that residents and/or
resident representatives are notified of a transfer from the facility.
On 4/11/24 at 1:21 PM, V2 RN/Registered Nurse DON/Director of Nursing was unable to provide any
documentation the Ombudsman or resident/resident representative was notified of resident transfers.
On 4/12/24 11:08 AM, V15 SSD/Social Services Director stated I only notify the Ombudsman if residents
discharge out of the building but not if they transfer to the hospital. I do not notify the resident/resident
representative in writing of transfers. I did not know I needed to do that.
Facility Application for Medicare/Medicaid, dated 4/9/24, documents 70 Residents reside in the Facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 4 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
Based on interview and record review, the facility failed to notify in writing, and maintain a copy in the
medical record notification of the bed hold policy to the resident/resident representatives of residents that
were reviewed for bed-holds. This failure has the potential to affect all 70 Residents residing in the Facility.
Findings include:
Facility Bed Hold and Return to Facility policy, revised 9/17/17, documents To ensure that residents and/or
resident representatives are notified of the facility bed-hold policy and conditions for return to facility upon
admission and at the time of a transfer from the facility.
On 4/11/24 at 1:21 PM, V2 RN/Registered Nurse DON/Director of Nursing was unable to provide any
documentation the resident/resident representative was notified of the bed-hold policy.
On 4/12/24 at 11:00 AM, V2 DON stated We have told the staff to send the bed hold with the residents at
the time of discharge. They are to make a copy and then it be put in the residents record but that has not
been done yet.
On 4/12/24 at 11:09 AM, V18 RN stated I have not documented in the chart a resident transfer with the bed
hold policy.
Facility Application for Medicare/Medicaid, dated 4/9/24, documents 70 Residents reside in the Facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 5 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to accurately code visual status for one (R12) of
20 residents reviewed for accurate resident assessments in a sample of 31.
Findings include:
On 4/9/24 at 9:30 AM, in R12's room above the head of R12's bed had a sign that documents (R12) is
legally blind- please introduce yourself, place call light in resident's hand, and have bed controls in reach. At
that same time, R12 stated he can see shadows but not details.
R12's MDS/Minimum Data Set, dated [DATE], documents under Vision - Highly Impaired.
R12's MDS/Minimum Data Set, dated [DATE], documents under Vision - Adequate.
On 4/10/24 at 2:00 PM, V5 Licensed Practical Nurse/LPN verified R12 was visually impaired, and visitors
needed to introduce themselves to the resident when entering the room.
On 4/12/24 at 12:00 PM, V12 LPN Careplan Coordinator verified R12 was visually impaired, and should be
documented as so on his MDS.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 6 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on observation, interview, and record review, the facility failed to develop a vision careplan for one
(R12) of 20 residents reviewed for careplans in a sample of 31.
Residents Affected - Few
Findings include:
Facility Comprehensive Care Plan policy, revised 11/17/17, documents To develop a comprehensive
careplan that directs the care team and incorporates the resident's services that are to maintain the
resident's highest practicable physical, mental, and psychosocial well-being.
On 4/9/24 at 9:30 AM, in R12's room above the head of R12's bed had a sign that documents (R12) is
legally blind- please introduce yourself, place call light in resident's hand, and have bed controls in reach. At
that same time, R12's three drawer dresser next to his bed had a cassette in a tape player with
headphones for books on tape, R12 stated he can see shadows but not details, and staff was observed in
the room and heard identifying themselves and telling the resident where things are in his room and on his
meal trays.
On 4/10/24 at 2:00 PM, V5 Licensed Practical Nurse/LPN verified R12 was visually impaired and
introduced herself when entering the room to identify herself to R12.
R12's current careplan does not document R12 is visually impaired.
On 4/12/24 at 2:00 PM, V15 Social Services Director verified R12 was visually impaired, and this should be
in his careplan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 7 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on observation, record review and interview, the facility failed to revise a Comprehensive Care Plan
for two residents (R52, R62) of 20 residents reviewed for Care Plan revision in a sample of 31.
Residents Affected - Few
Findings includes:
The facility's Comprehensive Care Plan dated 11/17/17 documents: To develop a Comprehensive Care
Plan that directs the care team and incorporates the resident's goals, preferences, and services that are to
be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial
well-being. The facility will develop and implement a comprehensive person-centered care plan for each
resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a
resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive
assessment. The care plan should be revised on an ongoing basis to reflect changes for the resident and
the care that the resident is receiving.
1. The current Care Plan for R52 documents R52 is oxygen dependent continuously.
The Order Summary Report for R52 does not include a physician order for the use of continuous oxygen.
On 4/9/24 at 10:00 am and 3:40 pm; on 4/10/24 at 1:40 pm; and on 4/11/24 at 8:05 am, R52 was lying in
bed in no respiratory distress and not using oxygen. There was no oxygen in the room for R52's use.
On 4/11/24 at 4:15 pm, V12 MDS (Minimum Data Set) Coordinator stated R52's Care Plan was just closed
today after being updated. V12 MDS Coordinator stated she does not see Oxygen on R52's current Care
Plan and R52 hasn't been on oxygen since he came off of Hospice in April of 2023.
2. R62's current Care Plan documents: (R62) has a tracheostomy. (R62) has an altered respiratory
status/difficulty breathing related to Chronic Obstructive Pulmonary Disease/COPD, respiratory failure,
tracheostomy. Oxygen at 10 liters per minute trache continuous.
(Internet Definition of Tracheotomy (Trache), dated 4/12/24 documents: Tracheostomy is a procedure to
help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the
neck. A person with a tracheostomy breathes through a tracheostomy tube inserted in the opening.)
R62's 11/1/23 Progress Note dated 11/1/23 documents: Old Trache site to neck clean and open to air.
R62's Progress Note dated 12/27/23 documents: (R62) has history of trache. Decannulated per
pulmonology. R62's Progress Note dated 4/9/24 documents: Trache decannulated five months ago; old
trache site still open and patient denies drainage from site when coughing.
On 4/9/24 at 10:40am, V6 Registered Nurse/RN stated that (R62) did not have a trache. On 4/10/24 at
2:15pm, V11 Licensed Practical Nurse/LPN stated that R62's trache was taken out on 10/24/23 and (R62)
will have surgery this month to close the (trache) hole.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 8 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Observation of R62 at 10:25 on 4/9/24 showed that R62 did not have a trache in place. There was a small
circular hole covered with border gauze where the trache was initially inserted.
On 4/11/24 at 1:25pm, V12 Minimum Data Set/MDS/Care Plan Coordinator stated that (R62's) Care Plan
should have stated History of trache instead of tracheostomy.
Residents Affected - Few
On 4/11/24 at 1:20pm, V2 Director of Nursing/DON stated that R62's Care Plan should have had info about
R62's airway was still open.
On 4/11/24 at 1:30pm, V1 Administrator stated, (R62) does not have a trache; his Care Plan should say
history of tracheostomy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 9 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure shower and nail care were
performed for one (R125) of two residents reviewed for activities of daily living in the sample of 31.
Residents Affected - Few
Finding include:
The facility's Certified Nursing Assistant policy and procedure, dated 5/2/2017, documents The Certified
Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living
and ensures the health, welfare and safety of all residents. Essential duties and responsibilities include:
Provide assistance in personal hygiene by giving bedpans, urinals, baths, backrubs, shampoos, and
shaves; and assisting with travel to the bathroom; helping with showers and baths. Document actions by
completing forms, reports, logs, and records.
The facility's Bathing-Shower and Tub Bath policy and procedure, revised 1/31/18, documents To ensure
resident's cleanliness to maintain proper hygiene and dignity. A shower, tub bath or bed/sponge bath will be
offered according to resident's preference two times per week or according to the resident's preferred
frequency and as needed or requested.
The facility's Nail Care policy and procedure, revised 1/25/18, documents Observe condition of resident
nails during each time of bathing. Note cleanliness, length, uneven edges, hypertrophied (thickened or
enlarged) nails. After bathing, use orange stick, and clean debris from around and under finger and
toenails. Document provision of care and pertinent observations.
The current Care Plan for R125 documents R125 with an ADL (activity of daily living) self-care/mobility
performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to)
recent nondisplaced fracture of cuboid (bone of foot) bone of the right foot, PVD (peripheral vascular
disease), S/P (status post) amputation of right and left great toes with surgical wounds, balance deficit,
unsteady gait and additional co-morbidities. Interventions include: Adjust provision of ADLS to compensate
for resident's changing abilities and Monitor/document resident's abilities for ADL's and assist resident as
needed.
On 4/09/24 at 10:32 am, 4/10/24 at 2:35 pm, 4/11/24 at 8:10 am, and 4/12/24 at 8:38 am, R125's
fingernails were overgrown and jagged to bilateral hands. R125's left 5th digit fingernail was grossly
overgrown at approximately a quarter of an inch.
On 4/10/24 at 2:39 pm, R125 stated he has not had a shower since he was admitted to the facility. R125
stated he just washes up at the sink on his own. R125 stated no one has come in and offered to trim his
toenails or his fingernails and stated, My fingernails really need cut, it has been a while.
On 4/10/25 at 2:35 pm, V2 DON/Director of Nurses, stated shower sheets are completed for each resident
on shower days. The CNA's are to give a reason why they didn't do shower, shave, clip nails or change bed
linens if they don't do them. The Shower Sheets are then turned into medical records to file.
The EHR (Electronic Health Record) Bathing Task for R125 documents R125 received a shower on 4/4/24
and a bed bath on 4/8/24. There are no other documented showers or baths in this EHR.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 10 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0677
Level of Harm - Minimal harm
or potential for actual harm
The Shower Sheets for R125, dated 3/28/24, 4/3/24, 4/4/24, and 4/8/24 do not document showers or nail
care was completed nor do they document the condition of R125's fingernails. There is no documentation
as to why R125's fingernail cares were not provided any of the days. The Shower Sheets dated 3/28/24 and
4/3/24 do not document why shower was not given. The Shower Sheet dated 4/4/24 contradicts the EHR as
shower being refused.
Residents Affected - Few
On 4/12/24 at 8:38 am, V18 RN/Registered Nurse stated nail care should be done on shower days or
anytime it's needed.
On 4/12/24 at 8:41 am, V16 CNA stated fingernail care is done on resident shower days or whenever they
need it during down time. If the resident refuses shower, then we do it during down time.
On 4/12/24 at 8:45 am, V17 CNA stated fingernail care is done on shower days. If the resident refuses their
shower, then nail care is done at that time or when we have time throughout the day.
On 4/12/24 at 2:00 pm, V2 DON stated she went to R125's room with fingernail clippers, confirmed R125's
fingernails needed cut and R125 allowed her to cut his nails.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 11 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, interview, and record review the facility failed to have orders for indwelling catheter
care and to record catheter output for two (R12 and R275) of five residents reviewed for indwelling
catheters in a sample of 31.
Findings include:
Facility Urinary Catheter Care policy, revised 2/14/19, documents To establish guidelines to reduce the risk
of or prevent infections in residents with an indwelling catheter. Routine hygiene (cleansing of the meatal
surface during daily bathing or showering) is appropriate. Catheter drainage bags will be emptied one time
on each shift.
1. On 4/09/24 at 2:19 PM, R12 was in bed with his catheter on the right side of the bed draining clear
amber urine. At that same time, R12 stated he has had his catheter for a while.
On 4/10/24 at 2:00 PM, and 4/11/24 at 10:30 AM, R12's catheter was at the side of bed draining clear
amber urine.
On 4/12/24 at 9 AM, R12 was up in a reclining chair with his catheter at the edge of the reclining chair
draining clear amber urine.
R12's current Order Summary Report, dated 4/11/24, has no orders to provide catheter care or to record
catheter output for R12.
R12's Treatment and Medication Administration reports (TAR/MAR) for April 2024 has no documentation
R12 received catheter care, has no documentation of R12's catheter output.
2. On 4/09/24 at 10:03 AM, R275 was in bed with his catheter on the left side of the bed draining cloudy
yellow urine. At that same time, R275 stated he has had his catheter for a while.
R275's current Order Summary Report, dated 4/11/24, has no orders to provide catheter care or to record
catheter output for R275.
R275's Treatment and Medication Administration report for April 2024 has no documentation R275 received
catheter care, has no documentation of R275's catheter output.
On 4/12/24 10:02 AM, V18 Registered Nurse/RN stated I have a hard time finding where the
CNAs/Certified Nurse Aides chart my catheters output. It is important to know the output of my residents
with catheters, but I am unable to access any outputs for these residents' catheters. I don't see an order for
catheter cares for (R12 and R275), and I don't chart on my TAR any catheter cares, or outputs if there isn't
any orders. At that same time the CNA charting was reviewed for catheter care and was unable to be found.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 12 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to implement enhanced barrier
precautions. This has the potential to affect all 70 residents in the facility.
Residents Affected - Many
Findings include:
Facility Enhanced Barrier Precautions/EBP, revised 4/8/24, documents Enhanced Barrier Precautions refer
to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that
employees targeted gown and glove use during high contact resident care activities. EBP are indicated for
residents with any of the following: wounds and/or indwelling medical devices, infection or colonization.
Indwelling medical device examples include: Central lines, urinary catheters, feeding tubes, and
tracheostomies. EBP should be used for any residents who meet the above criteria, wherever they reside in
the facility.
Facility provided a form, untitled and undated, documenting ten residents that consist of having wounds,
feeding tubes, urinary catheters, ostomies, ESBL/Extended-Spectrum Beta-Lactamase Escherichia Coli
and Klebsiella, and central lines.
Facility email to V2 RN/Registered Nurse DON/Director of Nursing, dated 4/8/24 from corporate,
documents for them to Implement EBP immediately effective 4/1/24.
During the survey from 4/9-4/12/24 from 8:30 AM to 4:30 PM, no EBP signs were posted anywhere
throughout the facility.
On 4/10/24 at 2:00 PM, V5 LPN/Licensed Practical Nurse performed R12's treatments to his bilateral feet,
ankle and suprapubic site wearing gloves only. At that same time, V9 RN/Registered Nurse Wound Nurse
performed resident's PROM/passive range of motion to his lower legs with only gloves on.
On 4/11/24, V9 RN Wound Nurse performed a Gastrostomy tube treatment for R52, open wound treatment
on R70's midback, and pressure ulcer treatments to bilateral heels and left buttocks on R26 with gloves
only.
On 4/12/24 at 9:00 AM, V17 CNA/Certified Nurse Aide stated she uses gloves when caring for residents
with catheters, ostomies, wounds, and feeding tubes. I did not know about wearing gowns with cares on
residents with (the above) until yesterday. At that same time, V16 and V17 both CNAs verified they only
wear gloves with cares, and all the CNAs work together to provide cares for everyone in the facility on both
wings A and B.
On 4/12/24 at 9:30 AM, V8 CNA was observed working with residents on A and B hall. At that same time,
V8 stated I am the shower aide today for the nursing home where I do showers for both wings. I only wear
gloves when giving showers.
On 4/12/24 at 11:01 AM, V2 RN DON stated I sent an email on 4/8/24 at 7:12 PM that we were going to
start EBP on 4/9/24 but State walked in. We got our signs this week, just educating now, (computer)
education to CNAs, and waiting for guidelines before starting implementation. This just came in effect on
4/1/24.
Facility Application for Medicare/Medicaid, dated 4/9/24, documents 70 Residents reside in the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 13 of 14
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
145248
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Morton
190 East Queenwood Road
Morton, IL 61550
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 0880
Facility.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145248
If continuation sheet
Page 14 of 14
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
10 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
F575 - The facility must post, in a form and manner accessible and understandable
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the April 12, 2024 survey of ARCADIA CARE MORTON?
This was a inspection survey of ARCADIA CARE MORTON on April 12, 2024. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ARCADIA CARE MORTON on April 12, 2024?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.