Inspection·March 20, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with new diagnoses of mental illness after admission was referred to the state agency for a level II PASARR (Preadmission Screening and Resident Review) evaluation for one of one resident (R25) reviewed for PASARR screening in the sample of 35. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR), dated 11/2018, documents It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in PASARR level I for all new and readmissions per requirements to determine if the individual meets the criterion for mental disorder (Severe Mental Illness/Severe Mental Disability), intellectual disability or related condition. Annually and with any significant change of status, the facility will complete the PASARR level one screen for those individuals identified per the Level II screen requiring specialized services. R25's current electronic medical record profile and Face Sheet, documents R25 was admitted to the facility on [DATE]. R25's most recent Level I PASARR (PASRR) evaluation, dated 6/23/22, documents at the time of evaluation R25 had mental health diagnoses of: Depression/Depressive Disorder. This same evaluation documents Review Date: 6/23/2022, Level I Outcome: No Level II Required. Resolved symptoms rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: Low level symptoms are present. However, submitted information supports that they are well controlled and there is no history of serious mental illness. If the individual's symptoms increase or other information suggests a potential serious mental illness, then the nursing facility must submit an updated screen to reevaluate the need for a PASRR Level II behavioral health evaluation. R25's Current Medical Diagnosis list, dated 3/20/25, documents R25 has been diagnosed with following diagnoses at or after admission, Bipolar on 6/25/22, Psychophysiologic Insomnia on 6/25/22, Vascular Dementia with Severe Psychotic Disturbance on 10/1/22, Unspecified Affective Mood Disorder on 1/31/24, Delirium due to known Physiological Condition on 6/25/22, and Unspecified Psychosis not due to Substance or Known Physiological Condition on 9/5/23. R25's medical record does not document that R25 has had any further PASARR screening or evaluation since admission to the facility or after R25's new diagnosis of new Severe Mental Illness. On 3/20/25 at 11:35 AM, V8 (Licensed Practical Nurse/Minimum Data Set) confirmed that R25 has not (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 7 Event ID: 145968 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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)