Arcadia Care Bloomington

In the surveyor’s words

From the most serious findings on record at Arcadia Care Bloomington, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 7, 2026

  Based on interview and record review, the facility failed to follow facility transportation policy resulting in transportation staff failing to properly secure a resident's wheelchair prior to driving, resulting in the wheelchair tipping backward and falling to the floor when the van accelerated from a traffic light due to being improperly secured in the wheelchair securement system. Additionally, staff failed to respond to a resident's request for medical attention and did not summon emergency medical services following the incident. These failures affect one of four residents (R12) reviewed for accidents in the sample list of 16. […]

• Immediate jeopardy, isolatedF760Jan 12, 2023

  Based on observation, interview and record review the facility failed to administer Lantus Insulin 85 units for one (R3) resident for a total of 25 days due to facility did not follow their own policy when reviewing a Physician order. This failure affects one (R3) of three residents reviewed for medication in the sample of 17. This failure caused R3 to experience a significant increase in R3's blood glucose levels resulting in R3 developing cellulitis requiring additional antibiotic therapy, with a potential for sustained elevated blood glucose levels resulting in diabetic coma and/or death. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R3 was initially not administered 85 units of Lantus Insulin. […]

• Actual harm, isolatedF550Jun 3, 2026

  Based on observation, interview and record review the facility failed to maintain a resident's privacy and dignity by failing to ensure shower rooms were protected from unauthorized entry during bathing and personal care for two (R84, R52) of two residents and failed to protect a resident's dignity and privacy by failing to cover an indwelling urinary collection bag for one (R39) of one resident reviewed for infection control in the sample list of 47. The facility's failure to protect residents from repeated privacy intrusions during bathing caused emotional distress, fear, embarrassment, and loss of personal privacy. These outcomes constitute actual harm as R84 and R52 experienced negative psychosocial consequences directly related to the facility's deficient practice. […]

• Actual harm, isolatedF689Oct 15, 2025

  Based on interview and record review the facility failed to implement appropriate accident and fall prevention interventions to prevent accidental removal of a feeding tube and falls for one of three residents (R1) reviewed for accidents on the sample list of six. These failures resulted in R1 pulling R1's feeding tube out requiring hospital reinsertion of the feeding tube and R1 falling and suffering a laceration above the left eyebrow requiring three sutures. Findings Include: The facility's Fall Prevention Program dated October 2024 documents the program's purpose is to assure the safety of all residents in the facility and is to include measures which determine the individual needs of each resident by assessing the risk of falls, implementing appropriate interventions to provide… […]

• Actual harm, isolatedF689May 24, 2025

  Based on interview and record review the facility failed to apply a vehicle safety restraint during transportation in the facility van for one of three (R1) residents reviewed for falls on the sample list of three. This failure resulted in R1's wheelchair flipping backwards in the facility van during transport and R1 sustained a left side rib fracture. Findings Include: The Motor Vehicle Safety Program dated January 2025 documents seat belts and shoulder harnesses (occupant restraint systems) must be worn or used whenever the vehicle is in operation. The vehicle may not move until all passengers have fastened their restraints. R1's Fall Follow-up Note dated 5/15/25 documents R1 fell from his wheelchair while in the facility van. […]