Arcadia Care Toulon
Arcadia Care Toulon in TOULON, IL — inspection on September 17, 2025.
Found 4 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.
Inspection Findings
to walk anymore since he was cold.On 9/16/2025 at 12:30 P.M., V2/Director of Nursing, confirmed on 7/18/25 she received an email concern from V19 that (R2's) jacket was taken from him by V6 because (R2) was attempting to exit the facility. V2 stated she called V6 to get her side of the story, but didn't investigate the matter any further. V2 confirmed V6 took the jacket and staff shouldn't take personal items from residents to address behaviors.On 9/16/2025 at 3:00 P.M., V15/CNA stated sometime in the middle of June, during shift change, V6 reported to me she took (R2's) jacket and hung it in the shower room.
When (R2) wears his jacket (R2) exit seeks more. I did see (R2's) jacket hanging in the shower room at that time. (R2) always complains of being cold, and (R2) always wants to wear a jacket.
For several weeks, back in June and July, (R2) didn't have a jacket, and we were having (R2) use a blanket to keep warm.On 9/16/2025 at 4:00 P.M., V6/Certified Nursing Assistant stated, I did take (R2's) jacket from him because of wandering behaviors.
When (R2) has his jacket on (R2) exit seeks more and makes attempts to leave the unit through the inner doors and doors to the outside. V6 also stated she doesn't think (R2) should have his jacket, since it causes (R2) to have behaviors.On 9/17/2025 at 10:00 A.M., V1/Administrator confirmed V6 did take (R2's) jacket because of wandering behaviors.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Toulon
700 E Main St Toulon, IL 61483
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to ensure an allegation of abuse was immediately reported to the Administrator and the State Agency for one of three residents (R2) reviewed for abuse in the sample of 5.FINDINGS INCLUDE:The facility's Abuse Prevention and Reporting- Illinois policy, dated 11/2016, documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must immediately report it to the administrator.
The policy also documents, Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but no more than two hours after the allegation of abuse.
Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.A facility Concern/Compliment Form, dated 7/18/2025, documents, Nature of concern, on 6/15/2025, V19/R2's family and V7/R2's Power of Attorney were visiting (R2) and noticed (R2) didn't have his jacket on. (R2) was asking where his jacket was because (R2) was cold. V6/Certified Nursing Assistant informed V19 and V7 that she took (R2's) jacket from him because (R2) wanted to leave the facility. V6 informed V19 and V7 that she hung (R2's) jacket in the shower room and wasn't going to give it back.As of 9/17/2025, the facility has no documentation of R2's allegation of potential abuse being reported to the state agency.On 9/16/2025 at 12:30 P.M., V2/Director of Nursing stated she received the complaint form on 7/17/2025 from V19.
However, she didn't notify V1/Administrator until the next day.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Toulon
700 E Main St Toulon, IL 61483
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to investigate an allegation of potential abuse for one of three residents (R2) reviewed for abuse, in the sample of 5.FINDINGS INCLUDE:The facility's Abuse Prevention and Reporting- Illinois policy, dated 11/2016, documents, Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.A facility Concern/Compliment Form, dated 7/18/2025, documents, Nature of concern, on 6/15/2025, V19/R2's family and V7/R2's Power of Attorney were visiting (R2) and noticed (R2) didn't have his jacket on. (R2) was asking where his jacket was because (R2) was cold. V7 says (R2) lived with her for 8 years prior to nursing home placement, and (R2) always wore a jacket around the house. V6/Certified Nursing Assistant informed V19 and V7 that she took (R2's) jacket from him because (R2) wanted to leave the facility and was having exit seeking behaviors. V6 informed V19 and V7 that she hung (R2's) jacket in the shower room and wasn't going to give it back.As of 9/17/2025, the facility has no documentation of an investigation regarding R2's allegation of potential abuse.On 9/17/2025 at 10:00 A.M., V1/Administrator confirmed she did not investigate R2's allegation of potential abuse.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Toulon
700 E Main St Toulon, IL 61483
SUMMARY STATEMENT OF DEFICIENCIES
two-assist stand pivot for transfers. V17/CNA verified that R4's Care Plan shows her (R4) as using a (full mechanical lift) for transfers and R5s shows him as using a (full mechanical lift) for transfers. V17/CNA stated, Well he's (R5) is not a (full mechanical lift) for transfers he is a two assist, he can stand. V17/CNA also stated that a nurse would need to watch the CNAs (Certified Nursing Assistant) do a transfer and document the assessment so it could be changed in the resident's care plan.On 9/17/25 at 10:00 AM, V18 (Certified Nursing Assistant/CNA) stated, (R4) is a sit-to-stand lift for transfers and (R5) is a two-assist stand pivot. I can't verify this as I don't know where to look on POC (Point of Care). I just go by word of mouth from other staff.On 9/17/25 at 10:10 AM, V2 (Director of Nursing/DON) verified that R1, R4 and R5s care plans have them as using the (full body mechanical lift) for transfers. V2/DON stated, There is a lack of communication amongst staff on how residents transfer but all of their (R1, R4 and R5) care plans show them as (full body mechanical lifts). V2/DON also stated that the CNAs (Certified Nursing Assistant) have report sheets that show how each resident is to be transferred for them to refer to and should be using them.
Facility ID: