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Complaint Investigation

Arcadia Care Morton

August 21, 2025 · Morton, IL · 190 East Queenwood Road
Citations 3
CMS Rating 1/5
Beds 106
Provider ID 145248
Healthcare Facility
Arcadia Care Morton
Morton, IL  ·  View full profile →
Inspection Summary

ARCADIA CARE MORTON in MORTON, IL — inspection on August 21, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0584
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During the week we typically schedule one laundry aide and two housekeepers, as well as me.

One housekeeper will take A hall and one will take B hall. I assist with doing the small dining room, offices, and running the floor machine throughout the facility.

We had a call in today, so we had one laundry, one housekeeper, and then me. I did spot checks today on B hall but couldn't get to everything. I still have a little more to do in some of the rooms.On 8/18/25 at 9:18 AM R1 stated housekeeping misses his room a lot for cleaning and states he does not believe housekeeping did much to his room over the weekend.On 8/18/25 at 2:14 PM R8 stated, My trash has not been taken out of my room since last Friday and no one has cleaned my room since then.

They are always short on housekeepers, and I get tired of my room not getting cleaned. I tell them all the time and then no one comes back to speak to me about it. I don't like when my room gets that dirty.On 8/19/25 at 1:45 PM, R3 was sitting on his bed in his room. R3's room had a very strong urine odor. R3 stated housekeeping often does not come in and clean his room because they do not have enough help.On 8/19/25 at 11:46 AM V13/LPN (Licensed Practical Nurse) stated housekeeping is terrible and they do not do the job correct.On 8/19/25 at 11:56 AM, V14/CNA (Certified Nursing Assistant) stated the facility is dirty and they only have one housekeeper on each side of the facility per day and they cannot get to it all.On 8/19/25 at 12:40 PM V19/CNA stated that the facility is often not clean and stated there is only one housekeeper that cleans one time a day and is not able to get all the cleaning done. On 8/19/25 at 12:11 PM V15/Human Resource Director provided the hours worked per department for housekeeping and laundry for the dates 8/15, 8/16, 8/17, and 8/18/25. On 8/15/25 there were a total of 22 hours worked in housekeeping and laundry, 8/16/25 a total of 23 hours worked in housekeeping and laundry, 8/17/25 a total of 15 hours worked in housekeeping and laundry, and 8/18/25 a total of 23 hours worked in housekeeping and laundry. V15 stated at this time they use the calculation of 0.45 x (times) the census to determine how many housekeeping/laundry/and maintenance staff to schedule. V15 verified at this time 37.8 hours per day should have been staffed for 8/15, 8/16, 8/17, and 8/18 and were not.On 8/19/25 at 1:55 PM V1/Administrator in Training stated We (the facility) have 37.8 hours per day for housekeeping/laundry/maintenance. We currently are not meeting that.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Morton

190 East Queenwood Road Morton, IL 61550

SUMMARY STATEMENT OF DEFICIENCIES

hospital because (V23) stated we should be sending (R2) since (R2) is still a full code. I kept telling (V23) I was waiting to hear back from (V1) to see what to do. To be honest I am a brand-new nurse and wasn't sure what to do. I did not document the time correctly in the progress notes. I accidently put 5:22 PM but it was technically around 11:00 AM when I sent (R2) out to the hospital.On [DATE] at 2:37 PM V1/Administrator in Training stated she was the prior Director of Nursing when R2 was sent out to the hospital on [DATE]. V1 stated, If any resident, including residents on hospice, are a full code and are actively dying staff should notify the physician and send the resident out to the hospital immediately.

There is no rule at the facility that staff must get a hold of the Director of Nursing first. (R2) should have been sent out immediately when (R2) was experiencing a change in condition and was actively dying. V1 verified five and a half hours was too long to wait to send R2 out to the hospital on [DATE].

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Arcadia Care Morton

190 East Queenwood Road Morton, IL 61550

SUMMARY STATEMENT OF DEFICIENCIES

was short 33 Nursing hours for 8/9/25 based on Facility Assessment staffing calculations.

The facility's Daily Assignment Sheet dated 8/10/25 documents the total Nursing Staff hours were 185 hours for the day.

V21 documented on Daily Assignment Sheet the facility was short 38.5 Nursing hours for 8/10/25 based on Facility Assessment staffing calculations.

The facility's Daily Assignment Sheet dated 8/16/25 documents the total Nursing Staff hours were 176.9 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 47.1 Nursing hours for 8/16/25 based on Facility Assessment staffing calculations.

The facility's Daily Assignment Sheet dated 8/17/25 documents the total Nursing Staff hours were 177.5 hours for the day. V21 documented on Daily Assignment Sheet the facility was short 41.5 Nursing hours for 8/17/25 based on Facility Assessment staffing calculations. On 8/20/25 at 11:56 AM, V21 (Regional Director of Operations) confirmed staffing shortages on the above dates based on minimum staffing calculations.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MORTON, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ARCADIA CARE MORTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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