Arcadia Care Morris: Missed Antibiotic Doses - IL
The resident, identified in inspection records only as R1, was supposed to receive Cephalexin, an antibiotic used to treat bacterial infections, at 8:00 PM on September 8 and again at 8:00 AM on September 9. Neither dose was given.
The registered nurse on duty that night offered a straightforward explanation when inspectors interviewed her on September 16. "During my shift, I never received any paperwork or pills," she said. "It is not our procedure to call the hospital to get the paperwork. Normally family or paramedics bring us the paperwork back."
The facility's Director of Nursing saw it differently. "We could have called the hospital and asked for the orders," she told inspectors. "R1 should not have missed the first dose, and we had the medications here in the facility."
That detail sits at the center of what inspectors found: the medication wasn't missing. It wasn't delayed in transit. It was already inside the building. The resident simply didn't receive it, because the nurse on duty was waiting for paperwork that nobody had taken responsibility for obtaining.
The Director of Nursing acknowledged what that kind of gap can mean for a patient on antibiotics. "If medications are not given as prescribed, the resident's infection can become worse," she told inspectors. She also said the facility should follow doctor's orders.
The inspection was conducted in response to a complaint and was completed on September 17, 2025. Inspectors cited the facility under F0684, which covers the requirement that residents receive care in accordance with their physician's orders. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The facility's own medication administration policy, dated January 2015 and due for review in May 2025, states that medications must be given to the right resident, at the right time, in the right dose, by the right route. Whether that review happened on schedule, and whether it changed anything about how staff handled discharge paperwork from outside hospitals, the inspection report does not say.
What the report does say is that a nurse and a director of nursing described two entirely different understandings of what the facility's procedure required. The nurse believed waiting was correct. Her supervisor believed calling the hospital was an option the nurse should have taken. Neither version of events resulted in R1 receiving Cephalexin on time.
Antibiotic timing matters in ways that are not abstract. Cephalexin is a time-sensitive drug, meaning it works by maintaining consistent levels in the bloodstream. Missed doses create gaps in that coverage. The Director of Nursing said so herself to inspectors, without prompting.
Arcadia Care Morris is a nursing and rehabilitation facility in Morris, a small city in Grundy County, roughly 60 miles southwest of Chicago.
The inspection report does not say what infection R1 was being treated for, how long R1 had been a resident, or what, if any, consequences followed the missed doses. It does not say whether R1's condition worsened. It does not say whether the facility updated its procedures after inspectors arrived, or whether the nurse who declined to call the hospital faced any internal review.
What it says is that a resident needed medication, the medication was there, and no one gave it to them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arcadia Care Morris from 2025-09-17 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ARCADIA CARE MORRIS in MORRIS, IL was cited for violations during a health inspection on September 17, 2025.
The registered nurse on duty that night offered a straightforward explanation when inspectors interviewed her on September 16.
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.