Arc At Hickory Point

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

66.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 552 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 64.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 205 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.68 therapist hours per resident per day in 2026Q1 — more than 91% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 64 beds and averages 59.4 residents a day — about 93% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.77 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.06 hrs/resident/day on weekends vs 4.68 on weekdays — 13% thinner on weekends. RN hours go from 0.33 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

46 citations, most serious first. The 23 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-02-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify a newly admitted resident as a potential elopement risk and failed to provide supervision and interventions to prevent elopement for one of four (R1) residents reviewed for elopement on a sample list of four. These failures resulted in R1, a severely cognitively impaired resident at risk for falls with impaired safety awareness, leaving the facility unsupervised on foot with no coat or shoes on with outside temperatures below freezing. R1 was found by family members six tenths of a mile from the facility in a restaurant parking lot near two interstates/highways eight hours after the resident was last observed in the facility. R1 suffered frostbite to bilateral feet great toes due to environmental exposure, hypothermia, a fracture to the proximal phalanx of left great toe, and a hematoma with laceration to the right frontal forehead requiring hospitalization.The immediate jeopardy began on 2/7/26 at approximately 11:00 pm when R1…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-09-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement pressure relieving interventions, assess, monitor, and treat a pressure sore, notify the physician of a reopened pressure sore/worsening pressure sore, and notify the physician of a facility acquired deep tissue injury for two of seven residents (R1, R4) reviewed for pressure sores in the sample list of seven residents. These failures resulted in R1's left elbow pressure sore progressing to an infected stage 4 pressure sore requiring hospitalization, surgery, a wound vacuum, and intravenous antibiotic theray and R4's right heel deep tissue injury deteriorating to an open unstageable pressure sore. The Immediate Jeopardy began on 8/13/24, when R1 obtained an open wound to her left elbow that was not reported to V14 (R1's) Physician/Medical Director. R1's left elbow wound progressed to an infected stage 4 pressure sore requiring hospitalization, intravenous antibiotics, surgical removal of R1's left elbow hardware and wound vacuum post surgery.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-04 · tag F0557 — isolated
  Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat residents with respect and dignity for one (R76) of three residents (R75, R60, R76) reviewed for respect and dignity in the sample list of 37 residents. This failure resulted in R76 feeling embarrassed and degraded with a low self-esteem after staff continued the incontinence check after R76 stated R76 had notified staff that R76 was continent of urine.Findings Include:R76's Medical Record reviewed documents R76 was admitted to the facility on [DATE] from a local hospital with Diagnoses of Seasonal Allergic Rhinitis, Polyneuropathy, Long Term (Current) Use Of Oral Hypoglycemic Drugs, Presence Of Right Artificial Knee Joint, Aftercare Following Joint Replacement Surgery, Chronic Obstructive Pulmonary Disease, Autoimmune Hepatitis, Presence of Left Artificial Shoulder Joint, Asthma, Hypoxemia, Type 2 Diabetes Mellitus Without Complications, and Parkinsonism.R76's assessment record reviewed V6 admission Nurse/License Practical Nurse, documents on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview and record review, the facility failed to ensure an oxygen cylinder was secured and stored properly for two residents (R71 and R1) in a sample list of 37 residents. Findings Include: On 3/01/2026 at 8:35AM, R71 had a portable oxygen cylinder located on the left side of R71's bed, not secured and not in use by the resident. R71 stated R71 does not use oxygen. On 03/01/2026 at 9:05AM, R1 had a portable oxygen cylinder located by the entry door inside R1's room. R1 stated R1 use to use oxygen and a BiPAP (Bilevel Positive Airway Pressure) machine but no longer uses either. R71's Physician Orders documented on 2/21/26, R71 receives two liters of Oxygen via Nasal Cannula every shift for Shortness of Breath. R1's Physician Orders dated on 1/27/26 Documents R1 is to receive Oxygen at three liters via nasal canula and Continuous Positive Airway Pressure (CPAP) machine. On 3/1/2026 at 1:25PM, V7 (Maintenance Director) stated there shouldn't be portable oxygen cylinders in the room as the oxygen cylinders are only for going out of the building for appointments.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete thorough fall investigations, failed to implement fall interventions and failed to supervise high fall risk residents for one (R7) resident out of three residents reviewed for Accidents in a sample list of twelve residents. Failing to provide supervision and implement fall interventions resulted in R7 falling and experiencing pain due to injury from an unwitnessed fall that required emergency services. Findings include:R7's medical record documents medical diagnoses as Encephalopathy, Falls, Vascular Dementia with Behavioral Disturbance, Abnormal findings on diagnostic imaging of other parts of musculoskeletal system, Anemia, Weakness and Pacemaker.R7's Minimum Data Set (MDS) dated [DATE] documents R7 as moderately cognitively impaired. This same MDS documents R7 requires supervision with toileting, bathing, dressing, bed mobility and transfers.R7's Fall Care Plan initiated on 11/10/25 documents R7 as being at risk for falls.R7's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-10-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify and report an alteration in skin integrity to prevent a pressure ulcer for one (R1) of four residents reviewed for quality of care. This failure resulted in R1 developing a Stage 2 pressure ulcer to the middle of R1's tailbone.Findings include:The facility's Skin Condition Assessment & Monitoring - Pressure and Non-Pressure Policy, dated 04/2025, documents that the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions, and ensuring interventions are implemented.R1's Care Plan, initiated on 05/22/2019, documents that R1 is at risk for developing pressure ulcers and other impairments to skin integrity related to decreased mobility, pain, and weakness. This Care Plan includes an intervention dated 05/23/2019 for monitoring, reminding, and assisting to turn/reposition R1 at least every two hours, more often as needed or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-10-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent a fall for two (R1, R4) of four residents reviewed for accidents. This failure resulted in localized swelling of clotted blood on R1's forehead and a displaced break to R4's left collarbone and localized swelling of clotted blood on R4's forehead.Findings include: The facility's Fall Prevention Program Policy dated 10/2024 documents that the purpose of this policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. This policy documents that residents will be observed approximately every two hours to ensure the resident is safely positioned in the bed or chair and provided care as assigned in accordance with the plan of care.On 10/09/2025 at 5:30 AM, R1 was lying bed and noted to have a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure fall interventions were in place for one (R1) of three residents reviewed for falls on a sample list of seven. This failure resulted in R1 falling and sustaining multiple left-sided rib fractures, a collection of blood in the chest cavity, and a left sided collapsed lung. Findings include: The facility's Fall Prevention Program policy provided by V1, Administrator, does not contain a date. This documents the purpose of this policy is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Guidelines for the Fall Prevention Program included the following components: methods to identify risk factors, methods to identify residents at risk, educate resident and resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-05-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify one (R4) resident's Sacral Deep Tissue Injury, failed to obtain and provide treatment orders, failed to updat careplan timely, and failed to implement pressure reducing interventions out of three residents reviewed for pressure ulcers in a sample list of eight residents. As a result of these failures, R4 had pain from her Stage 3 Sacral pressure ulcer which was acquired and worsened under the care of the facility. Findings include: R4's undated Face Sheet documents R4 admitted to the facility on [DATE]. This same face sheet documents R4 has medical diagnoses of Pressure Ulcers, Paraplegia, Urinary Tract Infection (UTI), and Osteomyelitis. R4's Electronic Medical Record (EMR) documents R4 admitted to the facility with a Stage Four Pressure Ulcer to her Right Ischium and Stage Four Pressure Ulcer to her Left Knee. R4's Minimum Data Set (MDS), dated [DATE], documents R4 as cognitively intact. This same MDS documents R4 is dependent…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify, assess, intervene, and treat pressure wounds for three (R171, R183, and R1) of four residents reviewed for pressure ulcers from a total sample list of 27 residents. These failures resulted in R171 and R1 developing facility acquited unstageable wounds underneath immobilizers. Findings include: The facility provided Skin Condition Assessment and Monitoring-Pressure and Non-Pressure Policy, dated 4/2025, documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the Certified Nursing Assistant (CNA). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. If the resident receives a shower, it will be necessary to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-17 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure pain medication was effective, available, and provided when pain was present for one (R179) of two residents reviewed for pain on the sample size of 27. These failures resulted in R179 going without pain medication, canceling his doctors appointment due to pain, and reporting pain of 8 out of 8. Findings include: The facility's pain management program policy, dated 4/2025, documents the facility will manage a resident's pain by developing an optimal pain management plan. This policy also documents the facility will use pharmacological and nonpharmacological interventions which will be included in the resident's care plan. R179's Care Plan, dated 4/11/2025, documents R179 is at risk for pain. This care plan includes interventions to administer pain medications and evaluate the effectiveness of pain interventions. On 4/15/25 at 8:59 AM, R179 was lying in bed in a slouched upright position, with the head of the bed slightly elevated. R179 stated, I have to stay in this position or else I am in pain. R179…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two staff members completed a mechanical lift transfer for one of three (R1) residents reviewed for accidents in a sample list of three residents. This failure resulted in R1 injuring R1's leg during a transfer and suffering a femur fracture requiring hospitalization and retrograde nailing. Findings include: The Facility's Mechanical Lift Policy, dated 5/26/2009, documents when using a mechanical lift for transfers two staff members need to be present. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is severely cognitively impaired. R1's care plan, dated 11/27/24, documents R1 transfers with a mechanical lift and assistance of two people. R1's Nurse Progress Note, dated 1/6/25 at 2:30 AM, documents R1 began yelling to get up around 12:15 AM, V6, Certified Nursing Assistant, assisted R1 out of the bed with a mechanical lift and transferred R1 to her wheelchair. The Note documents R1 was brought out to the nurses' station around 1:00 AM…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to develop a plan of care for a catheter and monitor urine output after catheter removal for two (R2, R8) of three residents reviewed for catheters on the sample list of eight. This failure resulted in R2 requiring emergency medical treatment where R2 was found to have Urinary Retention, Bacteremia, Acute Kidney Injury, and Sepsis. Findings include: 1. R2's Progress notes, dated 1/17/24 at 4:25 PM, documents R2 was admitted to the facility from the hospital with an indwelling catheter. R2's Hospital Discharge Summary. dated 1/17/24, documents R2 was experiencing urinary retention. and an indwelling catheter was placed on 1/12/24 and R2's renal function improved. This Summary documents an order for routine indwelling catheter care. R2's Progress note written by V13, Registered Nurse, dated 1/24/2024 at 7:04 AM, documents, CNA (V6, Certified Nurse's Assistant) was getting (R2) up for the day to dress and bathe (R2) when she noticed that (R2's) (indwelling) catheter was not inserted in the penis. The tip of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement fall interventions for one (R4) of three residents reviewed for falls in a sample list of three. Findings include: R4's Fall Risk assessment dated [DATE] documents R4 is a high fall risk. R4's Care Plan initiated 6/12/2026 documents R4 required assistance from staff for Activities of Daily Living (ADL's), toileting and transferring. R4's Care Plan initiated 6/12/2026 documents R4 is at risk for falls related to Confusion, Deconditioning, Gait/Balance problems, and History of Falls. R4's Electronic Health Record (EHR) documents an admission date of 6/11/2026 and diagnosed with Left Femur Fracture, Fall, Dementia, and Right Artificial Hip Joint. On 6/16/2026 at 9:15 AM, V6 (Family for R4) was at the bedside with R4. V6 stated they never leave R4 alone since they were worried R4 would fall. V6 stated R4 was to have an alarm but the one that was brought in was broken and was to be replaced. Since admission V6 stated R4 has not had a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · F2026-03-04 · tag F0577 — widespread
  Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure state survey results were accessible and contained all surveys which were completed in the last year. This failure had the potential to affect all 59 residents residing in the facility.On 3/1/2026 at 10:58 AM, R4, R22, R26 and R27 were interviewed for resident council meetings. On 3/1/2026 at 11:50 AM, during the resident council meeting, R4, R22, R26, R27 stated they were unaware of where the state survey inspection results were located. On 3/1/2026 at 12:00 PM, V12 (Receptionist) stated the survey book is located in the foyer in a drawer. V12 pointed to a four-drawer dresser in the foyer. A picture frame propped up on the dresser contained a sign that stated, Survey Results. At that time, the survey book was not located on top of or in the dresser. V1 (Administrator) confirmed it was not accessible to the residents as it was located in her office. V1 and V2 (Regional Director of Operations) stated that the book was missing surveys and needed to be updated. On 3/1/2026 at 12:20 PM, V2 stated the survey…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-04 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete wound assessments/measurements at least weekly and implement interventions to prevent wounds for three residents (R1, R6, R36) of five residents reviewed for wounds in a sample list of 37 residents.Findings Include: Facility Skin Condition Assessment & Monitoring – Pressure and Non – Pressure revised on 12/2025 documents a skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and is necessary. This also documents that residents identified will have a weekly skin assessment by a licensed nurse. Also, a wound assessment will be initiated and documented in the resident chart when a pressure and/or other non-pressure skin conditions are identified by licensed nurse. This document also states that wound assessment and monitoring that a licensed nurse shall observe condition of wound incision daily, or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer oxygen as ordered by the physician, change oxygen tubing and humidification weekly, and prevent possible cross contamination for four (R19, R36, R51, R58) of six residents reviewed for oxygen on a sample list of 37 residents. Findings:Findings Include: 1. R58's Care Plan revised 2/12/26 documents (R58) has altered respiratory status/difficulty breathing related to Pulmonary Hypertension, Obstructive Sleep Apnea, and Disorders of the Diaphragm. R58 has a current physician's order initiated 2/28/26 for continuous oxygen per nasal cannula at 3 liters per minute. On 3/1/26 at 9:30AM, R58 was observed resting in bed. The oxygen concentrator was set at 3 liters per minute, but the cannula and tubing in place to R58 was not attached to the concentrator. R58 stated R58 felt short of breath. V8 Licensed Practical Nurse (LPN) was notified. V8 went to R58's room and connected the tubing to the concentrator. V8 stated They must have…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-04 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medications were available by the pharmacy for two (R10, R150) of 16 residents reviewed for medications on the sample list of 37 residents. Findings Include: 1.) On 3/02/2026 at 8:15 AM, R10 stated when R10 was admitted (1/30/26) and readmitted (2/15/26) to the facility, R10's pain medication was not given because the facility did not have it. R10's physician orders dated 1/30/26 documents an order for Oxycodone Hydrochloride 30 milligrams (mg) one tablet by mouth every morning and at bedtime. R10's Medication Administration Record (MAR) for January 2026 documents R10's Oxycodone was not administered and to see progress note on 1/30/2026 and 1/31/2026. R10's progress notes for 1/30/26 at 7:56 PM does not document why the Oxycodone was not administered. R10's progress note dated 1/31/26 at 6:38 PM documents the Oxycodone was not available. R10's Medical Record does not document an attempt to call the backup pharmacy to obtain R10's Oxycodone.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-04 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  A. Based on Observation, Interview and Record Review, the facility failed to implement enhanced barrier precautions and Contact Precautions in accordance with facility policy for two residents (R71 and R61) on a sample list of 37 residents reviewed for transmission-based precautions. This deficient practice had the potential to increase the risk of transmission of multidrug-resistant organisms and communicable infections to other residents and staff. B. Based on observation, interview, and record review the facility failed to appropriately sanitize a glucometer between use on multiple residents for one resident (R33) of one resident reviewed for glucometer sanitization in a sample list of 37 residents. Findings Include: A. Facility Enhanced Barrier and Contact Precautions revised on 12/25 with chronic wounds or indwelling medical devices during high-contact resident care activities. This policy also documents Standard Precautions must be followed with all cares including gown and gloves must worn when providing the following cares: Dresing, Bathing/Showing, Providing Hygiene,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to answer call lights in a timely manner for one (R76) of three residents (R75, R60, R76) reviewed for call lights in the sample list of 37 residents.Findings Include:Grievance forms dated December 8 and 28, 2025 and February 3 and 26, 2026, all document residents having to wait extended times for help with various activities.Resident Council Minutes dated February 6, 2026, document six residents attended the meeting and documented staff need to answer call lights quicker.R76's Medical Record reviewed 2/24/26 documents R76 admitted to the facility on [DATE] from a local hospital with Diagnoses of Seasonal Allergic Rhinitis, Polyneuropathy, Long Term (Current) Use Of Oral Hypoglycemic Drugs, Presence Of Right Artificial Knee Joint, Aftercare Following Joint Replacement Surgery, Chronic Obstructive Pulmonary Disease, Autoimmune Hepatitis, Presence Of Left Artificial Shoulder Joint, Asthma, Hypoxemia, Type 2 Diabetes Mellitus Without Complications, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to assess the ability to self-administer medications for one of one resident (R10) on the sample list of 37 residents. Findings include: The Facility's Self Administration of Medication policy dated 4/2025 documents residents who request to self-administer drugs will be assessed using the Self Administration of Medications tool at the time of admission to determine if the practice is safe. 0n 3/1/2026 at 9:10 AM, a bottle of liquid Mucinex containing dextromethorphan 20 milligrams (mg), guaifenesin 400 mg, and phenylephrine 10 mg, a roller-ball tube of Aspercream (4% lidocaine), and a can of 4% lidocaine was sitting on R10's over the bed table. On 3/2/2026 at 9:05 AM, a bottle of liquid Mucinex, a roller tube of Aspercream, and a can of 4% lidocaine was sitting on R10's over the bed table. On 3/2/2026 at 1:32 PM, R10 stated R10 self-administers the Mucinex for congestion. R10 stated R10 self-administers the lidocaine and Aspercream which are used for pain management. R10's Electronic Health Record did not contain…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide clean bedding for one (R43) of 43 residents reviewed for environment on the sample list of 37 residents.Findings include: R43's admission Minimum Data Set assessment dated [DATE] documents R43 is cognitively intact. This assessment documents R43 requires partial to moderate assistance with activities of daily living. On 3/03/2026 at 9:28 AM, R43 was lying in bed. R43's pillowcase had brown smearing across the top of the pillowcase by R43's face. R43 was lying between the top sheet and the bottom sheet. Scattered brown crumbs were scattered along R43's upper body on top of the bottom sheet. R43 stated R43 eats in the bed and R43 would like to have clean bedding. R43 stated R43's bedding has not been changed since her room move on 2/21/26. R43's Daily Census in R43's Electronic Medical Record documents R43 moved rooms on 2/21/26. On 3/03/2026 at 9:33 AM, R43 was sitting in R43's wheelchair in R43's room. R43 stated R43's bedding had…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-04 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure the right to be free from chemical restraints by failing to assess the need for a psychotropic medication, failing to develop a plan of care for an antidepressant used for insomnia and failing to implement non-pharmacological interventions for insomnia for one (R10) of five residents reviewed for unnecessary medications on the sample list of 37 residents. Findings include: R10's Medication Administration Record (MAR) shows an order for mirtazapine (antidepressant) oral tablet 7.5 mg (milligrams) give 7.5 mg at bedtime for depression and insomnia start on 2/19/2026 at 8:00 PM. R10's Physician Progress Note dated 2/19/2026 written by V18 (Physician's Assistant) documents R10 was seen by V18 that day. V18 documented that R10 reported R10, can't sleep. This note documents V18 prescribed mirtazapine 7.5 mg at bedtime for Insomnia. On 3/3/2026 at 10:30 AM, R10 stated R10 has had a problem with sleeping R10's whole life from working swing shifts. R10 stated R10 preferred to fall asleep with the television on or R10 will…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$332,261 in federal fines across 4 penalties. 2 Medicare payment denials on record.

• $116,380 — penalty dated 2026-01-15
• $47,655 — penalty dated 2025-09-03
• $12,438 — penalty dated 2025-02-26
• $155,788 — penalty dated 2024-09-12
• Medicare payment denial — starting 2026-02-17 for 67 days
• Medicare payment denial — starting 2025-10-01 for 14 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ARCADIA CARE — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 36 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL