Health inspection·August 20, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe home like comfortable environment for three residents (R1, R2, R3) reviewed for safe homelike environment in a sample list of three residents.Findings Include:R1's current diagnosis list includes the following diagnoses: Chronic Neuropathy, Anxiety, and Major Depression.MDS (Minimum Data Set) dated 6/30/25 documents R1 is cognitively intact.On 8/19/25 at 11:15 AM, R1 was in her bed watching TV. The windowsill was covered in dust, dead spiders, and ants. The edge of the baseboard in R1's bathroom was crusted with brown debris and there was an odor of urine present. R1 stated there had been no toilet paper for several days last week. R1 stated I had to get family to bring me toilet paper, or I would have been without toilet paper. R1 stated there are ants in here all the time they crawl on the walls and the window.R2's current diagnosis list includes the following diagnosis: Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Diabetes, Anxiety, and Depression.R2's MDS (Minimum Data Set) dated 7/19/25 documents R2 is cognitively intact.On 8/19/25 at 11:28 AM, R2 was sitting up in his room in a wheelchair. The windowsills in R2's room were covered with dust and dead insects. The baseboards in R2's bathroom was crusted with yellow brown matter and there was a distinct odor of urine. Paint was peeling and several places from the wall of R2's room. R2 stated there are ants in here all the time. They just crawl all over the wall by the window. I take my meals in here and I've had ants get in my food. Regarding the toilet paper supply in the facility R3 stated They have been out of toilet paper more than once I keep some extra. R2 had two rolls of toilet paper in his drawer. When showing the toilet paper R2 keeps in the drawer, R2 pulled a sandwich out of the drawer in a plastic bag. The bread looked hard, and the meat was dry. R2 stated I've had this for a couple of days. I hate the food, so I keep stuff in here if I get hungry.R3's current diagnosis list includes the following diagnosis: Multiple Myeloma, Chronic Obstructive Pulmonary Disease, Depression, and Anxiety.R 3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact.On 8/19/25 at 11:35 AM, numerous chipped areas in the paint in R3's room were observed. There was an empty bed on the opposite side of R3's room with no mattress or linens with springs exposed.On 8/19/25 at 11:35 AM, R3 stated we ran out of toilet paper last week. We had to use whatever we had like napkins and tissues. We went days like that. It just made me feel disrespected and ignored. Regarding the insects, R3 stated I have seen ants and spiders in here but not for a while.On 8/20/25 at 11:30 AM, V6 and V5 certified nursing assistants (CNAs) stated there are ants in the rooms and V5 stated I have even seen them on residents which is bad for residents who can't brush them off. V5 and V6 verified there was a shortage of toilet paper a couple of days last week the facility sent someone out and bought some.On 8/20/25 at 11:45 AM, V1 Administrator stated, I became aware we were out of toilet paper on the floor last week and I went to (a local big box store) and purchased some toilet paper. A receipt was provided supporting this by the facility from a local (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 4 Event ID: 145371 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 145371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Bloomington 1509 North Calhoun Street Bloomington, IL 61701 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)