Arcadia Care On The Hill

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.

37.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 54 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 14.3% 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 42 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 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 251 beds and averages 121.2 residents a day — about 48% occupied, or roughly 130 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 2.80 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.17 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 is below 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 2.61 hrs/resident/day on weekends vs 2.88 on weekdays — 9% thinner on weekends. RN hours go from 0.22 to 0.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%.

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.

33 citations, most serious first. The 17 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · L2025-09-17 · tag F0658 — failed to meet professional standards of care — widespread
  Ensure services provided by the nursing facility meet professional standards of quality.
  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 competency of the Professional Nursing staff for 1 of 6 (R5) reviewed for Professional Standards in the sample of 50. This failure has the potential to affect all 128 Residents residing in the facility.The immediate jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. V6 failed to follow physician's order of administering Baqsimi (Glucagon) for low blood sugar, and instead disassembled prefilled Epinephrine and Narcan cartridges, combining pieces of both medication cartridges, and administered Epinephrine injection nasally. On 9/16/25 at 2:15 PM, V1, Administrator, and V2, Director of Nursing (DON), were notified of the Immediate Jeopardy. The surveyor confirmed by interview, observation, and record review, the Immediate Jeopardy was removed on 9/17/25, but noncompliance remains at 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-09-17 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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, observation, and record review, the facility failed to provide a resident in a crisis condition the correct medication for 1 of 6 residents (R5) reviewed for medication errors in the sample of 50. This failure resulted in the R5 not receiving his Glucagon when needed resulting in his blood sugar dropping to a critical low and being transferred to the hospital and subsequently admitted to the Intensive Care Unit (ICU).The Immediate Jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. V6 failed to follow physician's order of administering Baqsimi (Glucagon) for low blood sugar, and instead disassembled prefilled Epinephrine and Narcan cartridges, combining pieces of both medication cartridges, and administered Epinephrine injection nasally. On 9/16/25 at 2:15 PM, V1, Administrator, and V2, Director of Nursing (DON), were notified 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-08-24 · 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, observation and record review, the facility failed to monitor and supervise a resident with severe cognitive impairment for 1 of 1 resident (R4) reviewed for supervision in the sample of 5. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/31/23 when the facility failed to identify that R4 was missing, last seen at around 11:00AM and discovered entrapped on the elevator at 10:30 PM. This Past Noncompliance occurred from 7/31/23 to 8/1/23. On 8/22/23 at 3:03 PM, the V1, Administrator, V2, Director of Nursing (DON) and V22, [NAME] President of Operations, were notified of the Immediate Jeopardy. Findings include: R4's Minimum Data Set, dated [DATE], documented R4 had severally impaired mental cognition, however, R4 recalls long term memory and not short-term memory but is able to speak and answer simple questions. R4's admission Record, dated 8/10/23, documented R4 had diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety, heart disease 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.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  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 coordinate treatment care of a foot wound for 1 of 3 residents (R4) reviewed for wounds in the sample of 7. This failure resulted in a delay of treatment for R4, causing him to need more of his foot amputated due to the infection and lack of timely scheduling of the surgery.Findings include:R4's Physician Order Sheet (POS) for April 2026 documents a diagnosis of infective myositis, left foot; abscess of tendon sheath, left ankle and foot, other acute osteomyelitis, right ankle and foot; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere; non-pressure chronic ulcer of other part of right foot with muscle involvement without evidence of necrosis, hereditary and idiopathic neuropathy, chronic obstructive pulmonary disease, unspecified type 2 diabetes mellitus with foot ulcer, acquired absence of right great toe (9/19/2025), abnormal weight loss, hypertension and anemia. R4's POS documents an…

  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 before2025-10-17 · 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 interview and record review, the facility failed to implement, and document fall interventions for 1 (R7) of 3 residents who was newly admitted to the facility with hospital documentation of multiple vertebral fractures from a previous fall prior to being admitted to the facility of 3 residents reviewed for falls. This failure resulted in an alert resident (R7) falling twice at the facility and being transferred to the emergency room where she received IV fluids and narcotic pain medication. She sustained 2 skin tears from falls and was transferred to the emergency room due to post fall lethargy. Findings include:R7's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including compression fractures of second and fourth lumbar vertebra, burst fractures of T11-T12 vertebra, falls, low back pain, abnormalities of gait and mobility, muscle wasting and atrophy and lack of coordination.R7's Hospital Discharge Plan, dated 9/30/2025 documents she was in the…

  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 before2024-05-16 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely treat a urinary tract infection (UTI) for 1 of 3 residents (R3) reviewed for catheter care in the sample of 7. This failure resulted in R3 having a delay in treatment for a urinary tract infection and being admitted to the intensive care unit for septic shock. Findings include: R3's Care Plan, dated 1/9/2024, documents, I have Indwelling Catheter due to Obstructive Uropathy. Monitor/record/report to MD for s/sx (signs and symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R3's Minimum Data Set, dated [DATE], documents R3 was cognitively intact. R3 requires assistance from staff for activities of daily living (ADLs). R3's Physician Progress Note, dated 3/27/2024, written by V8, Urologist, documents, Chief Complaint Patient presents in office…

  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 before2024-01-17 · 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 interview, observation and record review, the facility failed to identify, treat, monitor and provide pressure reducing interventions for 3 of 3 residents (R1, R2, R3) reviewed for pressure ulcers in the sample of 11. This failure resulted in R2 and R3 sustaining unstageable necrotic pressure ulcers while in the facility. Findings include: 1. R3 admission Record, print date of 1/10/24, documents R3 was admitted on [DATE] and has diagnoses of Dementia, fracture of right femur, coronary artery disease and Type 2 Diabetes Mellitus. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is severely cognitively impaired, requires substantial maximum assistance from staff for bed mobility and transfers and is at risk for pressure ulcers. R3's admission Assessment, dated 10/26/23, documents R3's does not have any pressure ulcers. R3's Braden Assessment, dated 10/26/23, documents R3 is at high risk for pressure ulcers. R3's Alert Note, dated 11/10/23 at 2:43 PM, documents, New skin condition will evaluate.…

  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 before2025-11-26 · 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 interviews, observations, and record review, the facility failed to maintain resident safety, to document resident fall risk assessments before and after falls occur, and to follow interventions in place to prevent falls for 3 of 4 residents (R1, R3, R12) reviewed for resident safety in the sample of 13.The findings include: 1. R1's admission Record, dated 11/25/25, documents R1 was admitted to the facility on [DATE] with diagnosis of Encephalopathy, Type 2 Diabetes Mellitus (DM), uropathy, disorder of kidney/ureter, morbid obesity, malnutrition, benign prostatic hyperplasia (BPH), Urinary Tract Infections (UTI), major depressive disorder, anemia, atrial fibrillation (A-Fib), hypertension (HTN), legal blindness, adult failure to thrive, anxiety disorder, hallucinations, and schizoaffective disorder.R1's Care Plan, dated 11/17/25, documents R1 is at risk for falls related to impaired mobility due to morbid obesity. Interventions: 1/7/25: Bolsters added to bed as he is visually impaired so that he can…

  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 · F2025-09-17 · tag F0761 — failed to label and store drugs safely — widespread
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  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, observation, and record review, the facility failed to dispose of an expired Tuberculin vial and to safely secure medications in a medication cart while sitting in the hallway and available for all residents and visitors to get into. Reviewed for medication labeling and storage in the sample of 50. This failure has the potential to affect all residents living in the facility.The Findings Include: 1. On [DATE] at 10:18 AM, the Medication Cart on the end of the 200-hall was observed sitting in the hallway unlocked with no staff member around it. V7, Certified Nursing Assistant (CNA), stated, The Nurse had to go to central supply to get something and should be back soon. On [DATE] at 10:25 AM, V6, Registered Nurse (RN), came back to the cart and stated, The cart is broken, and we are waiting for the pharmacy to come fix it. We are unable to lock it and if we did, we can't get it back open. The drawers on the right side are locked, and we are not able to open those drawers, if needed, we have 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-09-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility failed to use hair nets while in the kitchen, to provide paper towels for hand hygiene, to label food items stored in the refrigerator, and to dispose of expired food items. This has the potential to affect all residents in the facility.The Findings Include:1. On 9/7/25 at 8:50 AM, while doing the initial kitchen tour, V18, Dietary Aide, and V19, Dietary Prep, were seen with no hair net on and upon surveyor entrance, both were seen going and getting a hairnet and putting one on.2. There were no paper towels available for handwashing at the handwashing sink.3. A large piece of ham was seen in the refrigerator wrapped in plastic wrap and undated.4. A large pan of sliced tomatoes was seen in the refrigerator covered in plastic wrap and undated.5. A pan of mixed vegetables was seen in the refrigerator covered in plastic wrap and undated.6. On the fourth-floor dry food storage room, there were three packages of hot dog buns that expired on 9/4/25.On 9/7/25 at 9:00 AM, V20, Cook, stated The items in the fridge should have been dated, especially since they are prepped 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-17 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement enhance barrier precautions and change gloves when soiled for 5 of 32 residents (R1, R4, R12, R40 and R121) reviewed for infection control in the sample of 50.Findings include: 1. On 09/09/2025 at 12:11PM V9 wound nurse and V16 Certified Nursing Assistant (CNA) entered R1's room. V16, CNA did not sanitize hands, don gloves, or gown prior to entering R1's room. Sign on wall beside R1's door documents enhanced barrier precautions. While standing at R1's bedside V16 sanitized hands and donned gloves. V16, CNA did not don a gown. V16 with gloved hands assisted V9 to roll R1 towards V16 for V9, wound nurse to do wound care to R1. Enhanced Barrier Precautions sign documents Stop, everyone must clean their hands, including before entering and when leaving room. Providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens,…

  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 · Dcited before2025-09-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  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 Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 6 residents (R12) reviewed for wound care in the sample of 50.The Findings Include:R12's admission Record, dated 9/11/25, documents R12 was admitted to the facility on [DATE] with diagnosis of Furuncle of groin, Abscess of groin, Infection following a procedure/surgical site, Open wound to right lower leg, Type 2 Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Atherosclerotic Heart Disease (ASHD), Congestive Heart Failure (CHF), and Hypertension (HTN).R12's Care Plan, dated 7/29/25, documents R12 has a potential for impairment to skin integrity related to decreased mobility. Interventions: Assess/record changes in skin status, follow facility protocols for treatment of injury, pressure relieving/reducing cushion to protect the skin while up in chair, pressure relieving/reducing mattress to protect the skin while in bed, use caution during transfers and bed mobility to prevent striking…

  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 before2025-09-17 · 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 interview, observation, and record review, the facility failed to prevent and assess a pressure ulcer for 1 of 7 residents (R10) reviewed for pressure ulcers in the sample of 50. Findings include: R10's admission record, print date of 9/11/25, documents R10 was admitted on [DATE] and has diagnoses of Multiple Sclerosis and Traumatic Brain Injury. R10's Minimum Data Set, dated [DATE], documents R10 is moderately cognitively impaired, requires partial to moderate assistance with dressing, toileting, bed mobility, and transfers. R10's Braden Observation, dated 6/6/25, documents R10 is at moderate risk for pressure ulcers. R10's Nursing Note, dated 7/17/25, documents, Writer obtained consent from resident for res (resident) to be seen and treated by (wound clinic). Services are to begin 7/24/25. R10's, undated, Wound Summary documents R10 has a Facility Acquired Pressure ulcer on the coccyx that was identified on 7/16/25. R10's, undated, Wound Summary documents on 7/21/25 R10's coccyx pressure ulcer was…

  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 before2025-09-17 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  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, observation, and record review, the facility failed to check for placement or residual of a Gastrostomy tube (G-tube) for 1 of 2 residents (R4) reviewed for G-tubes in the sample of 50. Findings include: On 09/07/2025 at 10:02 AM V3, Licensed Practical Nurse entered R4's room to give a 125 milliliter (ml) water flush. V3 turned off the feeding pump, disconnected the tubing from the G-tube and gave R4 a 125 ml water flush through the G-tube. V3 failed to check for residual.R4's admission Record, print date of 9/10/25, documents, R4 was admitted on [DATE] and has diagnosis of gastrostomy status.R4's Physician Order, dated 8/16/24, documents, Enteral Feed Order every shift Enteral - Check Tube Placement before feeding, Flush and Meds (medications).On 9/11/25 at 11:54 AM, V3, Licensed Practical Nurse (LPN), was questioned why she did not check for residual before giving the water flush. V3 stated, I checked for residual, then left the room, and then came back to give the water.On 9/11/25 at 12:17…

  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 before2025-06-24 · 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 provide adequate supervision to prevent falls in 1 of 3 residents (R2) reviewed for falls in the sample of 6. Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, lack of coordination, and reduced mobility. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, ambulated with wheelchair, and was dependent for toileting. R2's Undated Care Plan documents R2 is at risk for falls and is dependent for toileting. R2's Fall Risk assessment dated [DATE] documented R2 was at risk for falls. R2's 5/9/25 Progress Note by V25, Licensed Practical Nurse (LPN), documents, Writer entered room and noted resident lying on the bathroom floor next to toilet. Resident had BM (bowel movement) on the toilet and floor. Resident was assessed for injuries, vs (vital signs) taken, cleaned up dressed and continues visiting with family.…

  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 before2025-05-05 · 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 provide supervision for 1 of 1 residents (R3) reviewed for supervision in the sample of 7. This failure resulted in R3 leaving the facility going to liquor store obtaining alcohol and being sent by ambulance to the hospital for evaluation. Findings include: 1. On 4/23/2025 at 3:52PM V1, Administrator stated R3 is alert and orientated. V1 stated R3 knows he is supposed to sign out. V1 stated R3 took his wonder guard off. V1 stated the police found R3 at 3:00PM and took him to the hospital. V1 stated R3's family or family friend will sign R3 out and take R3 out in community. V1 stated he was last seen in the building around 1 PM. V1 stated R3 had been drinking. V1 stated the facility did not know R3 was gone. On 4/23/2025 at 4:20PM R3 stated he got an attitude yesterday and left. R3 stated, all my folks have passed away and I am only one left. R3 stated he walked about 13 miles. R3 stated he walked over by Clear Lake and was sitting on a bench when police…

  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 · D2024-10-29 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  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 notify Power of Attorney (POA) of change in condition for 1 of 3 residents (R2) reviewed for change of condition in the sample of 4. Findings include: 1. On 10/28/2024 at 10:29 AM, V3, R2's POA (Power of Attorney) stated she was not aware R2 was placed on an antibiotic and being treated for pneumonia until the facility notified her R2 was being sent out to the hospital on [DATE]. On 10/28/2024 at 11:00AM V1, Administrator stated R2's POA stated to V1 when she was notified R2 was sent to the hospital, she had not been made aware R2 was placed on an antibiotic for pneumonia. V1 stated V4, Registered Nurse (RN) stated she did not notify the POA of change in R2's condition. R2's chest x-ray report dated 10/21/2024 at 15:13 documents impression: right basilar opacity by one view, correlate clinically for atelectasis, chronic scarring, and/or pneumonia. R2's progress notes dated 10/21/2024 at 21:28 documents Xray services called with positive chest x-ray…

  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

“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

$229,143 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $73,800 — penalty dated 2026-04-22
• $98,313 — penalty dated 2025-09-17
• $47,515 — penalty dated 2024-04-01
• $9,515 — penalty dated 2023-08-24
• Medicare payment denial — starting 2025-10-08 for 62 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 33 rows in the source record cover these 17 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.

6 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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, FY2023). 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