Arcadia Care Morton: Delayed Hospital Transfer Violation - IL
The resident, identified in inspection records only as R2, was a full code, meaning staff were obligated to pursue all life-saving measures. R2 was actively dying and experiencing a change in condition when the nurse on duty decided to wait.
She was waiting to hear from the Director of Nursing.
The nurse, identified in the report as V23's counterpart, told inspectors she had been receiving pressure from another staff member to act. "I kept telling (V23) I was waiting to hear back from (V1) to see what to do," she said. "To be honest I am a brand-new nurse and wasn't sure what to do."
The call back never came in time. R2 was not sent to the hospital until roughly five and a half hours after the change in condition began.
Then came the paperwork. The nurse told inspectors she recorded the transfer time in the progress notes as 5:22 PM. The actual time was around 11:00 AM. "I did not document the time correctly in the progress notes," she said. "I accidently put 5:22 PM but it was technically around 11:00 AM when I sent (R2) out to the hospital."
The administrator in training at the facility, identified as V1, had served as Director of Nursing at the time R2 was transferred. She told inspectors the rule the nurse was waiting on simply does not exist. "There is no rule at the facility that staff must get a hold of the Director of Nursing first," V1 said. Any full-code resident who is actively dying should be sent to the hospital immediately, she said, with the physician notified at the same time.
V1 did not hedge the conclusion. "Five and a half hours was too long to wait to send R2 out to the hospital," she told inspectors.
The inspection was triggered by a complaint. CMS rated the deficiency at the lower end of its harm scale, citing minimal harm or potential for actual harm affecting a few residents. The citation falls under F0684, which covers the standard of care residents are entitled to receive.
What the rating does not capture is the position the nurse described: a brand-new clinician, uncertain, waiting on a supervisor who never called back, while a resident coded full was actively dying down the hall. The facility's own former Director of Nursing confirmed that no policy required the wait. The nurse waited anyway.
The progress note, meanwhile, sat in R2's chart with a time nearly six and a half hours off from when the transfer actually happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arcadia Care Morton from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 12, 2026 · Our methodology
ARCADIA CARE MORTON in MORTON, IL was cited for violations during a health inspection on August 21, 2025.
The resident, identified in inspection records only as R2, was a full code, meaning staff were obligated to pursue all life-saving measures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.