Arcadia Care Morris: Bruise Ignored After Resident Fall - IL
The resident, identified in inspection records as R5, had fallen near the nurses' station on March 20, 2026. Three staff members helped him back into his wheelchair. No injury was noted at the time. Because the fall was unwitnessed and R5 was on a blood thinner, the facility sent him to the hospital for evaluation, which was the right call. He came back on March 22.
Staff conducted a full body assessment when he returned. No new skin issues noted. The post-fall assessments continued through March 23 at 11:03 in the morning. Still nothing. No bruising. No skin breakdown. No concerns documented anywhere in the record.
Then a nursing assistant identified in the report as V17 helped R5 to the bathroom after he ate dinner, and saw what the assessments had missed.
The bruise was dark purple. It covered his whole right buttock.
V17 immediately told V6, a charge nurse. The next day, during shift change, V17 told the incoming CNA, identified as V21, about the bruise and confirmed that V6 already knew. V21 confirmed all of this to inspectors on March 26 at 2:50 in the afternoon.
What V21 could not confirm, because it did not happen, was that a physician had been called.
The facility's own Assistant Director of Nursing laid out exactly what should have occurred. V20, the ADON, told inspectors on March 26 that when staff find a bruise, they must document its size, location, color, and whether it causes pain. And they must notify the physician right away, because the resident might need to go back to the hospital for a higher level of care.
R5 was on a blood thinner. The facility already knew this, because it was the reason they sent him to the hospital after the fall in the first place. A massive bruise appearing on a blood thinner patient days after a fall is not a routine finding. It is the kind of finding that, as the ADON described it, might require a higher level of care.
The inspection report does not indicate a physician was ever notified about the bruise. It does not indicate the bruise was measured or its tenderness assessed. It does not indicate anyone went back and amended the post-fall assessments that had recorded no skin issues.
The facility's own accident and incident policy, revised in May 2022, requires documentation of any injury, the resident's condition, vital signs, and follow-up findings for a minimum of 72 hours after an incident. It requires parties to be notified.
R5 had fallen. He had been sent to a hospital and returned. Staff had assessed him repeatedly and found nothing. Then a nursing assistant found something significant enough that she reported it immediately, significant enough that the charge nurse was told that same night, significant enough that it was passed along at the next shift change.
And then, based on what inspectors found, it stopped there.
Federal inspectors classified the violation as causing actual harm to a small number of residents. That classification means inspectors concluded R5 was not merely at risk of harm. The harm had already occurred, in whatever form it took for a man on blood thinners to develop a bruise of that size without anyone calling his doctor.
The inspection was a complaint survey, meaning someone had reason to contact regulators before inspectors arrived.
R5 came back from the hospital cleared. His chart said so. His assessments said so. For at least a day, possibly longer, the only person who knew what was actually happening to his body was a nursing assistant who happened to help him to the bathroom after dinner.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arcadia Care Morris from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
ARCADIA CARE MORRIS in MORRIS, IL was cited for violations during a health inspection on March 30, 2026.
The resident, identified in inspection records as R5, had fallen near the nurses' station on March 20, 2026.
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.
Frequently Asked Questions
- What happened at ARCADIA CARE MORRIS?
- The resident, identified in inspection records as R5, had fallen near the nurses' station on March 20, 2026.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MORRIS, IL, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from ARCADIA CARE MORRIS or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 145623.
- Has this facility had violations before?
- To check ARCADIA CARE MORRIS's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.