Arcadia Care Morris

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 16, 2022

  Based on observation, interview, and record review the facility failed to protect a resident with dementia from unwanted touching of the breast. The resident is dependent on staff for all care and is not able to communicate with staff. This failure resulted in sexual abuse and repeated verbal abuse from R8 when R1's breast was touched and from the times R8 repeatedly cursed at her. Using the reasonable person concept, this failure would result in humiliation and degradation. The Immediate Jeopardy began on July 18, 2022, when the facility failed to ensure R1 was protected from unwanted sexual contact by another resident with a history of inappropriate sexual contact with other female residents. V1 (Administrator) was notified of the Immediate Jeopardy on August 11, 2022, at 4:02 PM. […]

• Actual harm, isolatedF580Mar 30, 2026

  Based on observation, interview, and record review, the facility failed to notify physicians of a resident's elevated Lithium level. This resulted in staff's continued administration of Lithium to the residents resulting in a resident's hospitalization with primary diagnosis of Lithium toxicity. The facility also failed to notify physicians and family members of a resident's injury (bruise) after an unwitnessed fall. This applies to 2 of the 6 residents (R1 and R5) reviewed for notification of change in condition and incident/accident in the sample of 9. The findings include:1. […]

• Actual harm, isolatedF684Mar 30, 2026

  Based on observation, interview, and record review, the facility failed to assess and address a resident (R1) who was having a change in condition. The facility also failed to do a complete follow up (post-fall) body assessment for a resident (R5) who had a fall incident.This failure resulted in a resident (R1) being lethargic throughout the morning shift until the early evening shift without appropriate intervention and was later hospitalized with a primary diagnosis of Lithium toxicity.This applies to 2 of 6 residents (R1 and R5) reviewed for change in condition and accident in the sample of 9. The findings include:1. […]

• Actual harm, isolatedF686Mar 15, 2024

  Based on interview and record review the facility failed to identify a pressure injury before becoming unstageable and failed to provide treatment to moisture associated dermatitis. These failures resulted in R4 developing an unstageable pressure injury to the sacrum. This applies to 1 of 4 residents (R4) reviewed for pressure injuries in the sample of 11. The findings include: On 3/15/24 at 11:34 AM, V10 Wound Licensed Practical Nurse (LPN) said R4 has pressure injury on her sacrum that was acquired at the facility and has been treated for a while. V10 said she is new to the facility and was not here when R4's wound was found. V10 said nursing staff does daily skin checks on residents during care and showers. V10 said she does weekly skin assessments for residents with wounds. […]

• Actual harm, isolatedF692Dec 8, 2023

  Based on observation, interview, and record review, the facility failed to monitor residents at risk for weight loss, offer nutritional supplements as ordered by the physician in order to prevent additional weight loss, and offer food substitutes for meals/snacks that were refused to prevent unplanned weight loss and maintain resident nutritional status. This failure resulted in R40 experiencing a 29.29% weight loss within 4 months of admission. This applies to 2 residents (R40 and R43) reviewed for weight loss in a sample of 31. The findings include: 1. R40's MDS (Minimum Data Set) dated 11/14/23 shows her cognition is intact. On 12/5/23 at 12:18 PM, R40 said, I have lost about 60 pounds since August. […]