Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arcadia Care Morris during CMS and state inspections, most recent first.
Failure to Provide Nail Care During ADL Assistance: Multiple residents who required help with grooming and hygiene were observed with long, dirty, uneven fingernails and black/brown debris under the nails. Several residents stated they wanted their nails cleaned and clipped, and one resident with stroke-related R-sided weakness and hand contractures had overgrown nails, including nails digging into the palm. The DON stated nail care is part of grooming care, and one resident with multiple comorbidities and substantial/maximal assistance needs reported that no one offers to clean or cut his nails.
Inadequate catheter and perineal care was observed for multiple residents with urinary devices and incontinence needs. A resident with an indwelling catheter had cloudy urine, sediment, bleeding, pain, and an unsecured catheter after staff reportedly pulled on it during care. Other residents were found with urine- and stool-soiled clothing, bedding, and catheter dressings, leaking or dangling urinary tubes, delayed brief changes, and incomplete peri-care that did not include the full frontal perineum, labial folds, urethra, or catheter area.
Failure to Follow Hand Hygiene, Gloving, and EBP Practices: Staff repeatedly entered resident rooms without complete PPE, used the same soiled gloves across multiple care tasks, and failed to perform hand hygiene before, between, and after resident care. Observations included CNAs changing soiled linens for a resident on EBP without gowns, a nurse and CNA transferring another resident without gowns, a nurse entering a contact precautions room without PPE and then touching the med cart without hand hygiene, and wound care and incontinence care provided to multiple residents while wearing soiled gloves. A resident’s nephrostomy drainage bag was also observed in a basin on the floor and leaking urine.
Failure to maintain clean and sanitary resident rooms: A resident was observed with crumbs, stains, and papers on the floor, another resident had food crumbs and black stains on a bathroom curtain that the DON described as mold, and a third resident had crumbs, paper, and brownish-black stains on the floor. The Housekeeping Director stated the rooms did not appear to have been cleaned that day, and the Administrator said resident areas are expected to be clean and sanitary.
Failure to provide ordered wound care and dressing changes: A resident with quadriplegia, MS, and chronic urinary catheter leakage was found heavily soiled with urine and feces, with a buttocks dressing that was saturated and nearly detached. Staff observed the resident’s skin to be macerated and irritated, while the wound care nurse and wound care physician confirmed the resident had recurrent dermatitis/MASD and that treatment was ordered BID and PRN.
Insufficient nursing staffing led to delayed and incomplete resident care. The facility scheduled fewer CNAs than required by its assessment, often leaving only 5 to 6 CNAs on day shift instead of 8, and staff were told to cancel shifts when census dropped. Residents reported long waits for toileting and assistance, including being left in feces and waiting during meals for help, while CNAs described working alone, delayed call light response, missed or delayed ADL care, and difficulty completing 2-person transfers and mechanical lifts.
Failure to provide a resident with clear notice of the daily private-pay cost when Medicare coverage for PT/OT ended. A cognitively intact resident with a left leg fracture and max assist transfer needs said she was not given the NOMNC copy, was unaware of appeal contact information, and was never told the daily rate if she chose to stay and pay privately. Staff said private pay was discussed and the admission contract included rates, but the facility could not show an SNF ABN with the daily cost when coverage ended.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple diagnoses and a history of falls was frequently left unsupervised, leading to repeated fall attempts and incidents. Despite ongoing agitation and risky behaviors, the care plan was not updated to include enhanced supervision or personalized fall prevention interventions. Staff and family confirmed insufficient monitoring, and facility leadership acknowledged that required care plan revisions and safety monitoring were not implemented.
A resident did not receive her monthly personal needs allowance after admission because the facility failed to promptly transfer and process her social security benefits from a previous facility. Despite the resident and her family raising concerns, the necessary application for representative payee was delayed, and the facility lacked a policy for handling such transfers.
A resident with multiple diagnoses, including a pressure ulcer with infection, did not receive the first scheduled doses of prescribed antibiotics due to delays in obtaining hospital discharge paperwork and medication orders. Despite having the medications on hand, staff did not administer them at the correct times, and the required orders were not promptly secured, resulting in a failure to follow physician instructions for medication administration.
Staff did not consistently follow infection control protocols, including hand hygiene and the use of gowns and gloves for residents on enhanced barrier precautions with indwelling devices or wounds. Multiple staff members provided care, such as perineal care, wound care, and blood sugar testing, without proper PPE and failed to perform hand hygiene after glove removal, leading to contamination of clean surfaces and equipment.
The facility failed to follow its water management plan for legionella and did not adhere to infection control protocols, including contact isolation and enhanced barrier precautions. Staff were observed not wearing appropriate PPE and not practicing proper hand hygiene during resident care, leading to deficiencies in infection prevention.
The facility failed to assist residents with personal hygiene and grooming, leaving several with long, dirty fingernails and unkempt appearances. Despite residents' requests for help, staff did not adequately address these needs, and observations showed that routine care tasks like nail trimming and changing soiled clothing were not consistently performed.
The facility failed to provide food in the correct consistency for residents on mechanically altered diets. Pureed chicken and vegetables were not properly processed, resulting in a grainy texture unsuitable for pureed diets. Additionally, residents on mechanical soft diets received meals with whole mushrooms and unpeeled potatoes, contrary to guidelines. These deficiencies affected nine residents and were confirmed by dietary staff during meal service observations.
A resident with multiple medical conditions, including cervical disc degeneration and morbid obesity, was unable to reach her call light and had to yell for help after a bowel movement. Despite her calls, a housekeeper did not respond, and the call light was found on the floor, out of reach. The facility's policy requires call lights to be accessible at all times, but this was not followed, as confirmed by the DON.
A resident with hemiplegia and hemiparesis was not assessed or provided with necessary splints to prevent further reduction in ROM. Despite being cognitively intact and requiring assistance with ADLs, the resident had contractures in her right arm, hand, and wrist, and expressed a desire for a therapist's assessment. An OT evaluation confirmed the need for orthoses to prevent further decline, but these were not initially provided.
A resident with a suprapubic and nephrostomy catheter had their catheter tubing and bag improperly positioned above the bladder by CNAs, contrary to the care plan and facility policy. This failure to maintain the catheter bag and tubing below the bladder level was confirmed by the DON, highlighting a deficiency in catheter care.
A resident with Parkinson's, acute kidney failure, and dementia did not receive breakfast meals on dialysis days due to a schedule change. The facility failed to adjust meal provisions, leading to significant weight loss. Staff were unaware of the need for meals or supplements, and no policy existed for dialysis sacked meals.
The facility failed to maintain proper central line dressing and assessment for two residents. One resident had a non-transparent, dirty dressing on her IV central line, while another had a loose PICC line dressing exposing the catheter. Required assessments and documentation were not conducted, contrary to facility policy.
A resident with dementia and severe cognitive impairment was prescribed Risperidone for restlessness without proper indications. The facility's documentation did not support the use of antipsychotic medication, as the resident showed no behavioral symptoms warranting such treatment. The DON acknowledged the lack of a valid diagnosis for the medication, and the consultant pharmacist had requested clarification on the antipsychotic usage.
Failure to Provide Nail Care During ADL Assistance
Penalty
Summary
The facility failed to provide nail care for residents who required assistance with ADLs, affecting 5 of 5 residents reviewed for nail care in a sample of 37. The active MDS for the residents showed they required assistance with grooming and hygiene. On observation, R10 was resting in bed with long uneven fingernails and black/brown substances under the nails, and stated she wanted her nails clipped and cleaned. R32 was observed with long dirty fingernails and black/brown substances under the nails and said she wanted staff to clean, file, or slightly clip her nails and was okay with staff cleaning them. R33 was resting in bed with long dirty fingernails and black/brown substances under the nails and stated she would love to have her nails clipped and cleaned. R34, who had right-sided weakness from a stroke and contracture of the right hand and wrist, was observed with long, jagged, uneven fingernails and brown discoloration on the nail beds. She stated she needed her fingernails clipped, especially on the right hand, and showed an overgrown right index fingernail curved at the tip and the 3rd and 4th fingernails digging into the palm of her right hand. R21's care plan showed an ADL self-care performance deficit related to multiple diagnoses, including limited mobility, history of pressure ulcer, type 2 diabetes mellitus with diabetic polyneuropathy, chronic kidney disease, and morbid obesity, and that he required one-person assist with personal hygiene. His MDS showed substantial/maximal assistance for personal hygiene and grooming, and he was observed with long fingernails filled beyond the fingertips with brown and black substances; he stated he wanted his fingernails cleaned and cut and that no one offers to cut or clean them. The DON stated that nail care is part of grooming care for residents.
Inadequate catheter and perineal care
Penalty
Summary
The facility failed to ensure indwelling urinary catheters and perineal care were provided in a manner intended to prevent urinary tract infection for 4 of 4 residents reviewed for catheter and perineum care. The report describes multiple observations of residents with urinary catheters that were unsecured, soiled, or not cleaned as part of incontinence care, along with delayed or incomplete perineal hygiene after bowel or bladder incontinence episodes. R11, who had diagnoses including rectal cancer, retroperitoneal abscess, colostomy status, diabetes, neuromuscular bladder dysfunction, muscle wasting, and obesity, was observed with cloudy urine, sediment in the catheter tubing, and later cloudy urine mixed with bright red blood after staff reportedly pulled on the catheter during care. The catheter was noted to be unsecured, and the resident reported sharp urethral pain and ongoing discomfort. The catheter remained unsecured over the following days. R10, who had quadriplegia, multiple sclerosis, neuromuscular bladder dysfunction, hydronephrosis, cystostomy status, and a history of UTI, was found with urine-saturated clothing, dressings, and bedding, leaking suprapubic and nephrostomy tubes that were dangling loosely, and fecal matter adhered to the buttocks and skin. R21, who had diabetes, chronic kidney disease, urinary retention, and morbid obesity, waited for incontinence care after a bowel movement, and when care was provided, only the back perineum was cleaned while the frontal perineum and urinary catheter were not cleaned. R15, who had diabetes and morbid obesity, was heavily saturated with urine and bowel movement, and staff cleaned only part of the perineal area, leaving the labial folds, urethra, and inner groin folds uncleaned.
Failure to Follow Hand Hygiene, Gloving, and EBP Practices
Penalty
Summary
The facility failed to follow infection prevention and control practices related to hand hygiene, glove use, gown use, placement of urinary drainage bags, and handling of soiled linens and clothing during care for multiple residents. The report states this applied to 10 of 10 residents reviewed for infection control in the sample of 37, including residents with enhanced barrier precautions (EBP) and contact precautions. The observations and interviews documented staff entering resident rooms without complete PPE, using the same soiled gloves across multiple care tasks, and not performing hand hygiene before entering, between tasks, or after leaving resident rooms. On June 30, 2026, R12 had an EBP sign on the door stating staff must clean their hands and wear gloves and a gown for high-contact care activities, dressing, transferring, and changing linens. The fitted sheet on R12’s bed was soiled with stool. Two CNAs entered the room to change linens without gowns, removed the soiled linens, applied clean linens, and did not disinfect the mattress. They also did not perform hand hygiene before exiting the room. On July 1, 2026, R28 had an EBP sign on the door, but a nurse and a CNA transferred R28 to bed without wearing gowns. R28 stated staff are supposed to wear a gown to protect his suprapubic catheter, but most of the time they do not. The report also documented multiple instances of poor hand hygiene and PPE use during care for residents with urinary catheters, wounds, and incontinence. A nurse entered R29’s room without gown and gloves despite contact precautions signage, then returned to the medication cart and touched items without hand hygiene. An LPN performed wound care on R7, donned gloves without hand hygiene, changed gloves without hand hygiene, cleansed and dressed the wound while wearing the same soiled gloves, and exited without hand hygiene. For R10, the nephrostomy tube/catheter bag was observed inside a basin on the floor and leaking urine; CNAs provided incontinence care without hand hygiene between tasks or before leaving, and a CNA later stated the bag had been in the basin for about 2 months because the catheter had been leaking. Additional observations included staff providing incontinence care to R21, R15, R11, R1, and R13 while wearing the same soiled gloves throughout care, not performing hand hygiene between dirty and clean tasks, placing soiled garments on the floor, and handling resident care and facility surfaces without hand hygiene. The facility’s DON stated staff providing direct care on EBP are required to wear gowns and gloves, perform hand hygiene between residents and before and after entering and exiting rooms, and keep the urinary bag hanging below the bladder and not touching the floor.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to provide a clean and sanitary environment for residents, affecting R8, R12, and R25. On June 30, 2026, R12 was observed in her room with lots of crumbs on the floor and in the corners, brown stains on the hardwood floor, papers under her bed, and some brown powder on the floor next to her bed. Housekeeping staff said they had already cleaned the room earlier that day while R12 was not present, but R12 stated no housekeeping staff had been in her room and that she had not left her room that day. The Housekeeping Director stated that R12’s room looked really bad and did not appear to have been cleaned that day. Also on June 30, 2026, R25 was observed lying in bed in a room with lots of food crumbs all over the floor and black stains on the bathroom curtain. R25 stated her room was only cleaned about twice weekly and had not been cleaned that day. The Housekeeping Director stated the black stains on the bathroom curtain looked like mold and said R25’s room did not look like it had been cleaned that day. On July 1, 2026, R8 was observed in bed in a room with lots of food crumbs, paper, and brownish-black stains on the hardwood floor. R8 stated housekeeping does not clean her room daily and that she has to ask when she sees staff cleaning nearby rooms. The Administrator stated the facility’s environment, including resident and dining rooms, is expected to be clean and sanitary, and that there should not be black stains or mold on bathroom curtains.
Failure to Provide Ordered Wound Care and Dressing Changes
Penalty
Summary
The facility failed to provide skin treatment and dressing changes according to physician orders for a resident with skin breakdown. The resident had multiple diagnoses including quadriplegia, multiple sclerosis, neuromuscular dysfunction of the bladder, weakness, hydronephrosis, cystostomy status, history of UTIs, and muscle wasting and atrophy to multiple sites. The resident was identified as high risk for skin breakdown on the Braden Scale and had a care plan addressing risk for moisture-related skin disorder to the bilateral buttocks related to fragile skin, incontinence, non-compliance with turning and repositioning, history of pressure ulcers, secondary to multiple sclerosis, muscle weakness, and diaper dermatitis. During observation, the resident was found heavily saturated with urine and had a bowel movement. Staff noted both urinary catheters were leaking, and the resident’s buttocks were covered with fecal matter that was adhered to the skin. A wound dressing on the buttocks, dated several days earlier, was heavily saturated with urine and fecal matter and was almost detached. The resident’s skin was described as reddish, purplish, macerated, soggy, and shriveled from prolonged urine exposure. The wound care nurse stated the wound treatment and dressing change were ordered twice daily and as needed, and the wound care physician stated the resident had recurrent dermatitis to the bilateral buttocks and posterior thighs related to leaking nephrostomy and suprapubic catheters, with orders for collagen and gauze to the buttocks.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its facility assessment and residents’ care needs. The assessment called for 1 RN, 2 LPNs, and 8 CNAs on day shift; 3 LPNs and 8 CNAs on evening shift; and 3 CNAs plus 2 additional staff on night shift. However, the nursing schedule from June 2026 through July 3, 2026, showed no days with 8 CNAs assigned to the day or evening shift, with day shift typically staffed by only 5 to 6 CNAs. On one day, a note next to two staff names stated, “If all show, go home,” leaving only 5 CNAs on the floor. On another day, one CNA called off and was not replaced, leaving 3 CNAs for the 100-400 units and 1 CNA for the villa. Residents and staff described delays in care and difficulty meeting basic needs because of the staffing levels. One resident, who had multiple diagnoses including multiple sclerosis, trigeminal neuralgia, convulsions, malnutrition, COPD, hypotension, and epilepsy, was dependent on staff for ADLs and reported being left in feces for 45 minutes because no one was available to assist. The resident also reported that during meal times, call lights were not answered until meals were finished because aides were feeding residents and no one else was available. Another resident, who was dependent on staff for ADLs and had diagnoses including hemiplegia, chronic pain, depression, and falls, stated that the facility was short-staffed and that CNAs were stressed and unable to perform their jobs as they should. Multiple CNAs and the DON confirmed the staffing shortages and the effect on resident care. CNAs reported working alone in the villa, being told no additional CNA would be assigned until census exceeded 18, waiting for help with two-person transfers and mechanical lifts, delayed call light response times of up to 25 minutes, and residents being left soaked in urine overnight because there was not enough staff. The DON stated he wanted additional nurses and CNAs but was told to cancel staff when census dropped. The facility’s fall list also showed an increase in unwitnessed falls from 3 in May 2026 to 15 in June 2026.
Failure to Provide Medicare Non-Coverage Notice and Daily Private-Pay Rate
Penalty
Summary
The facility failed to provide a resident with notice of the daily cost of services no longer covered by Medicare so the resident could make an informed decision about whether to continue skilled services and assume financial responsibility. The deficiency involved one of four residents reviewed for resident rights. The resident, R4, was admitted with multiple diagnoses including a displaced Maisonneuve's fracture of the left leg, other fractures of the left fibula and lower leg, unspecified fall, and difficulty walking. Her MDS showed she was cognitively intact, had impairment on one side of her upper and lower extremities, and required maximum assistance with transfers. R4's care plan documented ADL self-care deficits related to her fractures and gait/mobility problems, and later noted discharge planning to home with six steps to enter. R4 stated that her managed Medicare coverage for PT and OT ended and her appeal was denied. She said she was not given a copy of the NOMNC when she signed it, did not know there was a phone number to call to complain about the denial, and later received a copy only when she returned to the facility with her advocate. She also stated the facility told her she could file a second appeal, but she refused. R4 further stated she would have considered paying privately until her orthopedic follow-up, but the facility did not provide the daily private-pay rate and she still did not know it by the time of the interview. The Social Services Director said the managed Medicare company sent the NOMNC for issuance to R4 because coverage would end, and he offered private pay for more therapy, but R4 declined. The Financial Coordinator said the admission contract included the daily rate, but she did not email a copy to the resident or representative. The facility could not provide documentation showing that R4 was given an SNF ABN with the daily rates when the NOMNC was issued, and the SNF ABN in the record had blank lines for the reason Medicare may not pay and the estimated daily cost.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Failure to Revise Care Plan and Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to revise and implement care plan interventions to prevent falls and provide adequate supervision for a resident identified as high risk for falls. The resident had multiple diagnoses, including metabolic encephalopathy, diabetes, lack of coordination, cognitive communication deficit, muscle wasting, spinal stenosis, Parkinson's disease, a history of falls, and altered mental status. Despite these risk factors, the resident experienced frequent episodes of agitation, restlessness, and behaviors that could result in falls, as documented in progress notes and observed by staff. On several occasions, the resident was observed in common areas, such as the dining room and hallways, without staff supervision. The resident repeatedly attempted to stand, walk, or manipulate wheelchair footrests, often requiring redirection. In the absence of staff, another resident took it upon herself to watch over and redirect the resident, stating that there was not enough staff to provide supervision. Staff interviews confirmed that one-to-one care had been discontinued due to staffing shortages, and that supervision was provided only when possible. The resident's family member reported numerous falls since admission and was unaware of any new interventions to prevent further incidents. Review of the resident's care plan revealed that, despite multiple falls, interventions were not updated to address supervision, monitoring, or specific fall risk behaviors. The care plan did not reflect changes or personalized preventative measures after each fall, contrary to the facility's own Fall Prevention Program policy, which requires care plans to be revised with each incident. Facility leadership acknowledged that the resident was not on safety monitoring and that care plan interventions had not been reviewed or adjusted as required.
Failure to Transfer and Process Resident's Social Security Benefits for PNA
Penalty
Summary
The facility failed to ensure the timely transfer and processing of a resident's social security benefits from a previous facility, resulting in the resident not receiving her monthly personal needs allowance (PNA) after admission. The resident, who was alert and oriented, reported not receiving her $60 monthly allowance since her admission in June and stated that repeated requests to the former Business Office Manager yielded no results. The resident only learned recently that the transfer of her social security benefit had not been filed, which caused her distress. The family also raised concerns about the missing funds, and it was discovered that the previous facility had returned the resident's social security checks to Social Security upon her discharge. Interviews with facility staff revealed that attempts were made to contact the previous facility and Social Security, but these efforts were unsuccessful or not clearly documented. The facility did not have a policy regarding representative payee procedures, and the application to become the resident's representative payee for social security benefits was only submitted several months after admission. As a result, the resident's Medicaid payments were only partial, and the facility had not received the social security benefits to manage the resident's PNA as requested.
Failure to Obtain Orders and Administer Medications as Prescribed
Penalty
Summary
The facility failed to obtain necessary orders and administer prescribed medications as required for a resident who was admitted with multiple diagnoses, including a pressure ulcer with infection. After the resident returned from the hospital, there was a delay in receiving discharge paperwork and medication orders, as neither the family nor the hospital initially provided the necessary documentation. Despite the family informing staff that the hospital would fax the paperwork and later providing pill bottles, the facility did not promptly secure the required orders or administer the antibiotics as prescribed. As a result, the resident did not receive the first scheduled doses of Bactrim DS and Cephalexin at the prescribed times. The medication administration record confirmed that the initial doses were missed, and the antibiotics were not started until later than ordered. Staff interviews revealed that it was not standard procedure to call the hospital for paperwork, and the Director of Nursing acknowledged that the first dose should not have been missed, especially since the medications were available in the facility. The facility's policy requires medications to be administered according to physician orders, which was not followed in this instance.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols, specifically regarding hand hygiene and the use of enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. In multiple observed instances, certified nursing assistants (CNAs) and licensed nursing staff provided care to residents on EBP without wearing required gowns. During perineal care and wound care, staff did not change gloves between tasks, did not perform hand hygiene after removing gloves, and touched various surfaces and equipment with contaminated hands or gloves. For example, after providing perineal care to a resident with a urinary catheter, a CNA did not remove soiled gloves or perform hand hygiene before handling clean linens and touching the door. Similarly, a nurse performed wound care without changing gloves between tasks and failed to perform hand hygiene before leaving the room and handling clean supplies. Additional observations included staff performing blood sugar testing and other care for residents on EBP without wearing gowns, failing to perform hand hygiene after glove removal, and contaminating shared equipment such as medication carts and laptops. Facility policy required the use of gowns and gloves for care involving wounds or indwelling devices and emphasized hand hygiene as the primary method to prevent infection transmission. Despite this, staff did not consistently adhere to these protocols, as confirmed by interviews with the Director of Nursing and other staff.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management plan for legionella, as evidenced by the lack of documentation for critical maintenance activities. The Environmental Services Director, V27, admitted to not keeping records of the temperatures of the hot water boiler/storage tanks, the thermostat of the mixing valve, and inspections of the eye wash stations, ice machines, and cooling towers. The facility's policy required weekly verification and documentation of these elements to prevent Legionella growth, but there were significant gaps in the records, including missing temperature logs for specific weeks and months. The facility also failed to implement proper infection control measures, particularly concerning contact isolation and enhanced barrier precautions. Residents with infections requiring contact precautions, such as R27 and R41, were not consistently managed according to CDC guidelines. Staff members were observed interacting with these residents without wearing the necessary personal protective equipment (PPE), such as gowns and gloves, during high-contact activities. This non-compliance was noted during interactions with residents who had multidrug-resistant organisms, where staff failed to follow the facility's infection prevention and control program. Additionally, there were multiple instances of inadequate hand hygiene practices among staff members during the provision of care. Staff were observed not changing gloves or performing hand hygiene between tasks, which is critical to preventing the spread of infections. For example, during incontinence care for residents like R38 and R6, staff did not follow proper hand hygiene protocols, such as washing hands or using hand sanitizer after glove removal and before donning new gloves. These lapses in infection control practices were contrary to the facility's policies and contributed to the deficiencies identified during the survey.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene and grooming for several residents who were identified as needing such assistance. Observations revealed that multiple residents had long, jagged fingernails with black substances underneath, indicating a lack of proper nail care. For instance, one resident with dementia and macular degeneration was observed with long, dirty fingernails while eating, and another resident with hemiplegia had similar issues along with long facial hair, which they found embarrassing. The deficiency was further highlighted by the residents' own requests for assistance, which were not adequately addressed by the staff. One resident, who was cognitively intact but physically impaired, expressed the need for help with nail care and removal of facial hair, yet these needs were not met. Another resident, who was dependent on staff for hygiene due to musculoskeletal impairment, was observed with overgrown facial hair and dirty nails, despite having a care plan that included regular nail care. Additionally, the facility's staff failed to maintain the residents' dignity by not changing soiled clothing in a timely manner. One resident was left with a chunk of dried oatmeal on their shirt for several hours, and instead of changing the shirt, the staff merely removed the oatmeal. The Director of Nursing acknowledged that nail care and shaving should be part of the routine care provided during shower days, but the observations indicated that these tasks were not consistently performed, leading to the residents being unkempt and with dirty fingernails.
Inappropriate Food Consistency for Mechanically Altered Diets
Penalty
Summary
The facility failed to provide food in the appropriate consistency for residents on mechanically altered diets, affecting nine residents. During meal service observations, it was noted that pureed chicken and vegetables were not properly processed, resulting in a grainy texture with pieces that required chewing, which is not suitable for residents on pureed diets. The facility's guidelines specify that pureed foods should have a smooth, pudding-like consistency, similar to mashed potatoes. However, the pureed chicken and vegetables served did not meet these standards, as confirmed by taste tests conducted by the Regional Dietary Certified Manager and the Contract Dietary Consultant. Additionally, residents on mechanical soft diets received meals that included whole sautéed mushroom slices and roasted potatoes with skin, contrary to the facility's guidelines for mechanical soft diets. These guidelines require that vegetables be chopped or diced into bite-sized pieces and that potato skins be excluded. The menu and recipe for the meal in question indicated that ground baked chicken with sauce and mashed potatoes should have been served, but this was not followed. The oversight affected residents who were on mechanical soft, ground meat diets, as well as those on mechanical soft diets.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was always within reach, leading to a situation where the resident, identified as R12, was unable to call for assistance. R12, who has multiple medical diagnoses including cervical disc degeneration, spinal stenosis, and morbid obesity, is totally dependent on staff for dressing and toileting hygiene. On the morning of October 1, 2024, R12 was observed repeatedly yelling for help because she needed to be changed after a bowel movement and was wet with urine. Despite her calls for help, a housekeeper continued with her tasks outside R12's room without responding. Upon inquiry, R12 stated she did not know where her call light was, and it was found on the floor, out of her reach. The facility's policy requires that call lights be within easy accessibility to residents at all times, and that staff respond to residents' requests in a timely and courteous manner. However, this policy was not adhered to in the case of R12, as evidenced by the call light being out of reach and the lack of response to her calls for help. The Director of Nursing confirmed that all staff are responsible for responding to calls for help and that call lights should always be within reach of residents. This incident highlights a failure in the facility's adherence to its own policies regarding resident care and call light accessibility.
Failure to Provide Splints for Resident with Contractures
Penalty
Summary
The facility failed to assess and provide necessary splints to a resident, identified as R63, to prevent further reduction in range of motion (ROM). R63, who has multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed to have weakness and contractures in her right arm, hand, and wrist. Despite being cognitively intact and requiring maximum assistance with activities of daily living, R63 was not provided with any splint or positioning device for her right hand and wrist. The resident expressed a desire to be assessed by a therapist for potential use of a splint or positioning device. An occupational therapy evaluation conducted on October 1, 2024, confirmed that R63 had contractures in her right hand, fingers, wrist, and elbow. The occupational therapist recommended the use of an elbow extension orthosis and a resting hand orthosis with finger separators to prevent further decline in function. The therapist also suggested that R63 should wear these orthoses initially for one hour, gradually increasing to eight hours as tolerated. The Director of Nursing stated that nursing staff are expected to report any changes in residents' ROM to ensure timely therapy evaluation and implementation of necessary interventions.
Improper Positioning of Catheter Tubing and Bag
Penalty
Summary
The facility failed to ensure proper positioning of urinary catheter tubing and bags for a resident, identified as R3, who has a suprapubic catheter and nephrostomy catheter due to multiple sclerosis and other medical conditions. During an observation, two Certified Nursing Assistants (CNAs) were seen providing care to R3, and they positioned the catheter tubing and bag on top of a pillow above the resident's bladder. This improper positioning was noted again later in the day, indicating a failure to maintain the catheter bag and tubing below the bladder level as required. The Director of Nursing confirmed that the urinary tubing and bag should be positioned below the bladder to ensure proper drainage and prevent backflow, which could lead to infection. The resident's care plan, which included specific instructions to position the catheter bag and tubing below the bladder, was not followed. The facility's policy on urinary catheter care also emphasized maintaining a downhill flow of urine to prevent backflow, which was not adhered to in this instance.
Failure to Provide Adequate Nutrition for Dialysis Resident
Penalty
Summary
The facility failed to provide adequate nutrition to a resident undergoing dialysis treatment. The resident, who has a history of Parkinson's disease, acute kidney failure, and dementia, was not given breakfast meals on days when dialysis was scheduled early in the morning. Despite a change in the dialysis schedule from afternoon to early morning, the facility did not adjust meal provisions accordingly. On multiple occasions, the resident returned from dialysis without having eaten, and staff were unaware of the need to provide meals or nutritional supplements. The resident experienced significant weight loss since admission, indicating a failure to meet nutritional needs. Staff interviews revealed a lack of communication and coordination regarding the resident's dietary needs and dialysis schedule. The dietitian was not informed of the resident's poor meal intake and had not assessed the resident in person. Additionally, there was no policy in place for providing sacked meals for dialysis patients, leading to further neglect in meal provision. The resident's power of attorney noted the resident's weight loss and attempted to supplement nutrition with Boost drinks, but the facility did not consistently provide these supplements. The lack of a structured plan for meal provision before and after dialysis contributed to the resident's inadequate nutrition and weight loss.
Failure to Maintain Proper Central Line Dressing and Assessment
Penalty
Summary
The facility failed to ensure that the central line insertion sites for two residents were visible under a transparent dressing for proper assessment and monitoring. One resident, with multiple diagnoses including discitis and osteomyelitis, had an IV central line on her right chest covered with non-transparent tape, and the dressing was not clean or intact, with edges curling up and dirt present. The dressing had not been changed since September 26, 2024, despite being observed in poor condition on multiple occasions. Another resident, with diagnoses including osteomyelitis and a chronic ulcer, had a PICC line with a dressing that was loose and exposing the catheter. The dressing was not changed but only secured with tape, and the resident continued to have the same dressing for several days. There was no documentation of necessary assessments such as arm circumference and catheter length to ensure the catheter had not migrated. The facility's policy required a transparent dressing and regular assessments, which were not followed.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive antipsychotic medications without proper indications for use. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and dementia without behavioral disturbance, was prescribed Risperidone for restlessness. However, the resident's Minimum Data Set indicated severe cognitive impairment without any behavioral symptoms, and the behavior monitoring documentation did not show any agitation or restlessness, except for one episode of grabbing others. The Director of Nursing acknowledged that restlessness is not a valid diagnosis for the use of antipsychotic medication. The resident's care plan and consultant pharmacist recommendations highlighted the need for a specific diagnosis for antipsychotic usage, which was not provided. Progress notes from hospice doctors indicated that the resident experienced intermittent restlessness but could be redirected and had periods of lethargy, sleeping for extended hours. Despite these observations, the facility continued the antipsychotic medication without appropriate justification, leading to the deficiency identified by the surveyors.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 158 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Morris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Serenity Estates At Morris | 0.9 mi | ★★★★★ | 21 | 0 |
| Goldwater Care Marseilles | 14.8 mi | ★★★★★ | 11 | 0 |
| Alden Estates Of Shorewood | 16.2 mi | ★★★★★ | 6 | 0 |
| Alden Courts Of Shorewood | 16.2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Wilmington | 16.6 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.