Arcadia Care Toulon: Transfer Safety Failures - IL
Inspectors flagged the violations during a September 2025 complaint inspection, finding that certified nursing assistants had bypassed the required equipment for residents identified in facility records only as R1, R4, and R5. All three had care plans explicitly specifying full-body mechanical lift transfers. All three were moved without one.
The Director of Nursing, identified in the inspection report as V2, did not dispute the findings. She told inspectors there had been "a lack of communication amongst staff" about how the residents were supposed to be transferred. She also confirmed that CNAs are given report sheets at the start of their shifts listing each resident's transfer method, sheets they are supposed to consult and follow.
That means the information existed. It was written into care plans. It was printed on the sheets staff carried in their pockets. Nobody used it.
CMS rated the harm level as minimal harm or potential for actual harm, and noted only a few residents were affected. But the mechanical lift requirement exists because moving a resident without one when their body requires it creates real risk, to the resident's bones, muscles, and skin, and to the workers doing the lifting.
What the inspection captured was not a single lapse or a new employee unfamiliar with a resident's needs. Three residents. The same gap across their care. The Director of Nursing's explanation pointed inward, at the facility's own systems, at a communication breakdown she acknowledged but did not explain how it had gone undetected or for how long.
The report sheets were there. The care plans were there. The lifts were not used.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arcadia Care Toulon 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 Toulon in TOULON, IL was cited for violations during a health inspection on September 17, 2025.
All three had care plans explicitly specifying full-body mechanical lift transfers.
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.