Arcadia Care Rock Island

In the surveyor’s words

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

• Immediate jeopardy, patternF689Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to adequately supervise a known wandering resident (R1), failed to have systems in place to monitor the front door alarms after hours and failed to have interventions in place for a known faulty (electronic wandering device) door alarm system for one (R1) of twenty-two residents reviewed for elopement/wandering. These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of Vascular Dementia, eloping from the facility to a grassy area out front of the building, by a curb, close to a busy road attempting to get on a city bus. […]

• Immediate jeopardy, isolatedF600Jul 22, 2025

  Based on observation, interview, and record review the facility failed to implement interventions to ensure a resident was free from physical abuse resulting in potential injury for 2 of 3 residents (R2, R11) reviewed for abuse in the sample of 12. The immediate jeopardy began on 6/11/25 at 6:50 PM when R1 returned to the facility from being evaluated at the acute care hospital after grabbing R11 by the neck. R1's care plan was updated to include 1:1 supervision on 6/11/25. No evidence was found of R1 being on 1:1 supervision until 6/18/25 after the second incident when R1 pushed R2 to the floor. V1 (Administrator) was notified of the Immediate Jeopardy on 7/18/25 at 11:23 AM. […]

• Immediate jeopardy, isolatedF689Sep 14, 2021

  Based on interview, and record review, the facility failed to provide a resident with safety interventions and provide adequate supervision to ensure R1, a newly admitted resident with a recent history of a suicide attempt, did not engage in behavior of self-harm and maintained a safe environment free of hazards for one of three residents R1 reviewed for supervision, in a total sample of three. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on September 10, 2021, the facility remains out of compliance at Severity Level 2, as the facility continues to ensure a process and procedure is in place to screen R1 for potential suicidal risk upon re-admission, provide a comprehensive assessment of R1 and R1's environment to ensure the safety upon return to the… […]

• Actual harm, isolatedF684Jul 22, 2025

  Based on interview and record review the facility failed to assess respiratory status for one resident (R3) who displayed respiratory changes of three residents reviewed for change of condition in the sample of five.This deficient practice resulted in a delay in the assessment of the resident's respiratory status and subsequent need for additional medical intervention.The findings include:Physician Order Summary Report indicates R3 was admitted to the facility on [DATE] with diagnoses that include, Dysphagia, Cerebral infarction, Generalized Anxiety Disorder, Gastrostomy, Acute Respiratory Failure with Hypoxia.On [DATE] V7, LPN (Licensed Practical Nurse) stated that she was R3's assigned nurse on [DATE]. […]

• Actual harm, isolatedF580Mar 17, 2022

  Based on record review and interview the facility failed to notify the physician of a significant change in a residents condition related to refusal of medications, medications being unavailable, refusal of food and liquids and orders for a urinalysis not completed for one resident (R1) of three reviewed for nursing care in the sample of three. This failure resulted in R1 being admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility's Change in a Resident's Condition or Status policy, dated 5/2017, documents Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. […]