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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arcadia Care Rock Island during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and recent COVID-19 illness, who was clearly documented as full code, was found unresponsive and not breathing by a CNA, who notified an LPN. The LPN confirmed full code status, initiated chest compressions, and called 911 while the CNA assisted. When EMS arrived, staff were performing compressions and attempting ventilation with a BVM that lacked a mask and was not connected to O2, contrary to facility policy requiring use of a face mask or resuscitator bag to provide effective breaths. EMS noted the improper BVM setup, that compressions were stopped during the handoff, and that the resident was cold with rigor mortis present, indicating the facility failed to perform CPR in a manner that provided adequate oxygenation.
A resident with a non-removable lower extremity cast did not receive required shift assessments or documentation for cast care after readmission, as previous orders were not continued and new ones were not obtained. The resident later experienced increased pain, a wet and odorous cast, and was found to have complications including a wound and signs of sepsis, with staff confirming that regular assessments were not performed.
A resident with significant physical impairments was transferred without the required full mechanical lift when the device's battery failed. Staff manually transferred the resident using a gait belt, contrary to the care plan and facility policy, and there was confusion among staff regarding whether proper authorization was obtained. The DON confirmed no approval was given and that backup equipment was available.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A facility licensed for 177 beds did not employ a full-time qualified social worker, instead assigning the Social Service Director role to a former CNA with no social work license, certificate, degree, or prior experience, contrary to the facility's own job requirements.
A resident with multiple medical conditions and dependent on staff for toileting was denied assistance to use the bathroom by a CNA, who instructed the resident to use an incontinence brief instead. The resident was left unassisted until the next shift, resulting in distress and a significant mess. The DON confirmed that staff should honor such requests, and the incident was identified as a dignity concern.
A resident with multiple medical conditions voiced a grievance regarding a CNA, but was not interviewed or informed of the outcome by administration. Staff confirmed that while internal actions were taken, the resident was not kept updated as required by the facility's grievance policy.
A resident with multiple medical conditions and dependent on tube feeding did not receive the registered dietician's recommended feeding regimen or liquid protein supplement. Despite clear recommendations, staff did not initiate the changes, and the resident continued on the previous feeding schedule. Staff interviews revealed confusion about the process for implementing dietician recommendations, and the facility lacked a policy on this matter.
A resident with a G-tube and multiple complex medical conditions did not have current physician orders for G-tube site care, despite the care plan indicating the need for such care. An LPN and the DON confirmed that these orders were missing, and facility policy requires physician orders for essential care upon admission.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with a history of respiratory issues and enteral feeding exhibited increased anxiety, persistent cough, and unusual behaviors, but the assigned LPN did not assess lung status or check oxygen saturation as required by facility policy. Later, another LPN found the resident with low oxygen saturation and unresponsiveness, prompting emergency intervention. Staff interviews and documentation review confirmed that respiratory assessments and monitoring were not performed or recorded as per protocol.
The facility's Infection Preventionist lacked complete specialized training, having only completed 15 of 23 required modules in the CDC's training program. This deficiency could potentially impact all 79 residents, as the IP has been in the role since December 2023 without full certification.
The facility failed to provide written bed hold policy notices to two residents and their representatives within 24 hours of hospital transfers, as required. This deficiency was identified through record reviews and interviews, revealing that the facility did not communicate the policy during multiple hospitalizations for both residents.
A facility failed to include a resting hand splint in a resident's care plan. The resident's orders required wearing the splint at specific times, but it was observed on a shelf instead. The care plan lacked documentation of the splint, as confirmed by the RN/Care Plan Coordinator.
The facility failed to update the care plans for two residents undergoing dialysis. One resident's care plan did not reflect the removal of an AV fistula and the placement of a new central dialysis port, lacking specific dialysis orders and emergency contact information. Another resident's care plan did not document a dialysis catheter in the left upper inner thigh, missing monitoring instructions for the site. These deficiencies were confirmed by nursing staff.
A resident with a history of kidney disease and UTIs did not receive daily catheter flushes as ordered, leading to a deficiency in care. The MAR showed flushes were given only as needed, and staff failed to document low urine output. Confusion over order changes and lack of communication contributed to the oversight.
A facility failed to apply a resting hand splint for a resident as per the prescribed schedule. The resident's treatment record lacked documentation of the splint's application, and observations showed the splint was not in use. The resident expressed discomfort with the device, and staff were either unfamiliar with or unaware of the splint's use. The physical therapist confirmed the necessity of the splint, highlighting a lapse in adherence to the care plan.
The facility failed to provide specific dialysis orders for two residents requiring dialysis services. One resident, with end-stage renal disease, lacked orders for the type of dialyzer, flow rate, and care of the dialysis port. Another resident's orders were generic, lacking an individualized dialysis prescription. Facility staff confirmed that specific orders were kept in the dialysis unit, and the facility did not have access to them.
The facility failed to document and offer pneumonia vaccinations to two residents upon admission, as required by their policy. One resident agreed to receive the vaccine after surveyor intervention, while another declined. The Infection Preventionist admitted to missing the immunizations on admission and confirmed the residents had no prior vaccinations.
The facility failed to document and offer COVID-19 vaccinations to three residents upon admission. After a surveyor's inquiry, the Infection Preventionist documented that one resident agreed to receive the vaccine at a future clinic, while two others declined. The oversight was acknowledged, and a vaccination clinic was scheduled.
The facility failed to ensure immediate reporting of verbal abuse allegations as required by their policy. A CNA reported hearing another CNA verbally abuse a resident but did not report it immediately to the Administrator. Other staff also witnessed similar incidents but delayed reporting. The resident involved was hard of hearing and confused, and appeared well-cared for at the time of the survey.
Inadequate CPR and Oxygenation for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate CPR and oxygenation to a resident who was a documented full code. The resident had multiple diagnoses, including hemiplegia and hemiparesis, cerebral infarction, type 2 diabetes, vascular dementia with behaviors, anxiety disorder, dysphagia, and a recent COVID-19 illness. The resident’s POLST and care plan clearly indicated full code status, with instructions that CPR would be initiated if the resident’s heart and respirations stopped. On the night in question, a CNA found the resident unresponsive and not breathing around 4:25 a.m. and notified the LPN, who confirmed the resident’s full code status, called 911, and went to the resident’s room to begin CPR. According to nursing progress notes and staff interviews, the LPN checked for a pulse, found none, and began chest compressions, then the CNA took over compressions while the LPN retrieved the crash cart and called 911. When the LPN returned, she resumed compressions and the CNA began bagging the resident. However, the ambulance run report and paramedic interview documented that upon EMS arrival, one staff member was performing chest compressions and another was attempting ventilation with a BVM that did not have a mask attached and was not connected to oxygen. The paramedic stated that the staff member had only the T-piece in the resident’s mouth and that proper oxygenation with a BVM requires application of the mask. The DON also confirmed that without the mask attached to the bag, adequate ventilation cannot be provided. EMS personnel further observed that staff stopped compressions when EMS entered the room to allow EMS to take over, and that the resident was cold to the touch with rigor mortis noted in the jaw. The LPN later acknowledged that the bed likely was not flattened during CPR and that she found the resident cold with no pulse, stating the resident had not just died minutes before. The facility’s CPR policy required provision of basic life support, including CPR, prior to EMS arrival, and specified the use of a face mask or resuscitator bag to ventilate two breaths after 30 compressions, with each breath delivered over one second to cause chest rise. Despite this policy, the staff’s use of a BVM without a mask and without oxygen, and the failure to ensure proper setup for effective ventilation, resulted in CPR that did not provide adequate oxygenation to the resident.
Failure to Assess and Document Cast Care Leading to Delayed Identification of Complications
Penalty
Summary
The facility failed to implement and document appropriate interventions for the assessment and care of a non-removable lower extremity cast for one resident. According to the facility's Cast Care policy, staff are required to assess the cast every shift for tightness, circulation, motion, sensation, drainage, odor, and skin irritation, and to document these assessments and report abnormal findings to a physician. After the resident was readmitted from the hospital, there were no orders in place for cast care, and staff did not obtain new orders or continue previous ones. The resident's Treatment Administration Record previously included orders to check circulation, movement, sensation, and temperature (CMST) every shift, but these were discontinued upon readmission, and no new orders were obtained. The resident subsequently reported increased pain in the right lower extremity, and it was noted that the cast was damp and had an odor. Staff did not perform or document regular cast assessments as required, and the wound nurse only became aware of the lack of cast care orders after being informed of a wound inside the cast. The orthopedic evaluation later identified increased pain, a wet splint, concerns for neurovascular compromise, infected pressure ulcers, and sepsis. Staff interviews confirmed that regular assessments were not performed and that the wound could have been identified sooner if proper procedures had been followed.
Failure to Follow Care Plan for Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident using a full mechanical lift as required by the resident's care plan. The resident, who had diagnoses including congestive heart failure, morbid obesity, muscle weakness, and muscle wasting, was assessed as having no cognitive impairment and being dependent on staff for transfers. The care plan specified that transfers should be performed with a mechanical lift and two staff members. However, during an incident, the mechanical lift's battery died while transferring the resident, and staff proceeded to manually transfer the resident using a gait belt, with one staff member lifting under the resident's arms and another guiding the hips. The resident reported feeling unsafe and stated that she was told she needed the lift at all times for transfers. Staff interviews revealed inconsistent accounts regarding whether permission was obtained from the DON to perform the manual transfer, with one CNA stating that approval was given and another denying the DON's involvement. The DON confirmed that he was not present and had not authorized a change in the resident's transfer method, emphasizing that such changes require therapy evaluation or a physician's order. Facility policy required the use of mechanical lifting devices for high-risk residents except in emergencies, and backup batteries and additional lifts were available on each floor. Despite these policies and resources, the staff did not follow the resident's care plan or facility protocols during the transfer.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient monitoring or preventive measures to address these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing the necessary supervision to safeguard residents from potential accidents.
Failure to Employ Qualified Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility, licensed for 177 beds with a current census ranging from 66 to 81 residents, failed to employ a full-time qualified social worker as required. The individual serving as the Social Service Director (SSD) was previously a Certified Nursing Assistant (CNA) and assumed the SSD position at the end of May, without holding a license, certificate, or degree in social work or any related field, and without prior social work experience. The Administrator in Training confirmed that the SSD was not licensed and could not provide documentation of qualifications in social work. The facility's job description for the Director of Social Services requires at least a bachelor's degree in psychology, sociology, or social work, or a Licensed Clinical Social Worker's certificate, none of which were met by the current SSD.
Resident Denied Dignified Assistance with Toileting
Penalty
Summary
A resident with diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia, hemiparesis, cerebral infarction, dysphagia, and Raynaud's syndrome, who was assessed as having no cognitive impairment and being dependent on staff for toileting, reported being denied assistance to use the bathroom upon returning from the hospital. The resident stated that after requesting to be taken to the bathroom due to an urgent need for a bowel movement, a Certified Nursing Assistant (CNA) told him to use his incontinence brief instead of assisting him to the restroom, stating, "We aren't going to walk you in there today. You can just go in your depends and we can clean it up." The resident expressed shock and distress at this response and reported having to wait until the next shift for assistance, resulting in a significant mess that required cleaning. The CNA involved confirmed that the resident was already wet when she began changing him and, upon his request to use the bathroom, told him it was unnecessary since he was already wet. The CNA relayed the request to another aide but did not assist the resident further. The Director of Nursing acknowledged that staff are expected to honor resident requests to use the bathroom unless it is unsafe, which was not the case in this situation. The incident was identified as a dignity concern, as the resident's request for assistance with toileting was not respected, contrary to facility policy and residents' rights.
Failure to Inform Resident of Grievance Status
Penalty
Summary
A deficiency occurred when the facility failed to follow its grievance policy by not keeping a resident informed about the status of a grievance. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia, cerebral infarction, dysphagia, and Raynaud's syndrome, reported frustration over a complaint involving a certified nursing assistant (CNA). The resident stated that while staff were aware of the complaint and had reported it, no one from administration interviewed them or provided any follow-up information regarding the outcome of the grievance. Interviews with facility staff revealed that the Director of Nursing was informed of the incident and that the administrator categorized it as a customer service issue, resulting in a staff in-service and a temporary suspension for the CNA involved. However, staff acknowledged that the resident was not spoken to about the investigation or informed of the resolution. The facility's grievance policy requires prompt acknowledgment and a timely written response to grievances, which was not provided in this case.
Failure to Implement Dietician Recommendations for Tube Feeding
Penalty
Summary
The facility failed to implement the registered dietician's recommendations for a resident who was dependent on tube feedings for all nutrition and hydration needs. The resident had multiple diagnoses, including acute and chronic respiratory failure with hypoxia, hemiplegia, cerebral infarction, dysphagia, and Raynaud's syndrome, and was noted to have a low BMI and significant weight loss over a short period. The dietician recommended a specific tube feeding regimen (Osmolite 1.5cal at 60ml/hr for 20 hours daily) and the addition of liquid protein twice daily. However, these recommendations were not initiated, and the resident continued to receive continuous feedings over 24 hours without the prescribed liquid protein supplement. Interviews with staff revealed a lack of clarity and follow-through regarding the process for implementing dietician recommendations. The LPN stated that dietary recommendations are typically acted upon by earlier shifts and that it is standard practice to obtain physician orders for such recommendations promptly. The DON indicated that recommendations should be implemented within 24 hours but was unsure if this occurred in practice. The facility was unable to provide a policy regarding the implementation of dietician recommendations, and as of the time of the survey, the recommended changes had not been made to the resident's care.
Lack of Physician Orders for G-Tube Site Care
Penalty
Summary
A deficiency was identified when a resident with a G-tube, who had diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia, cerebral infarction, dysphagia, and Raynaud's syndrome, did not have physician orders for G-tube site care during the review period. The resident's care plan indicated a need for tube feeding and specified that local care to the G-tube site should be provided as ordered, with monitoring for signs and symptoms of infection. However, a review of the physician's orders for the relevant period showed no orders for G-tube site care. During interviews, an LPN confirmed that there were previously orders for G-tube site care but none were currently present in the system, despite the importance of cleaning the site to prevent infection. The DON also stated that standard orders for residents with G-tubes should include head of bed elevation, G-tube flushing, and site care, and acknowledged that the absence of these orders was an oversight. Facility policy requires physician orders for essential care at admission, but this was not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess Respiratory Status Following Change in Condition
Penalty
Summary
The facility failed to assess the respiratory status of a resident who exhibited notable respiratory changes, including increased anxiety, a persistent dry cough, and behaviors such as repeatedly wiping his tongue. Despite these symptoms, the assigned LPN did not perform a lung assessment or obtain an oxygen saturation level, only taking vital signs, which were not documented. Later, another LPN found the resident to be lethargic and pale, with an oxygen saturation of 78%, and the resident became unresponsive, requiring emergency intervention and transfer to the hospital. Staff interviews revealed uncertainty about protocols for respiratory assessment, and documentation showed that required assessments and monitoring were not consistently performed or recorded as per facility policy. The resident had a medical history including dysphagia, cerebral infarction, generalized anxiety disorder, gastrostomy, and acute respiratory failure with hypoxia, and was receiving enteral nutrition. Facility policies required respiratory assessments with any change in condition, especially for residents with risk factors such as tube feeding and respiratory diagnoses. However, these protocols were not followed when the resident displayed respiratory changes, resulting in a delay in assessment and medical intervention.
Inadequate Training of Infection Preventionist
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) with specialized training in infection prevention and control, which could potentially affect all 79 residents in the facility. The job description for the Infection Preventionist Nurse, reviewed in November 2021, requires maintaining current knowledge of federal, state, and local regulations and compliance with infection control procedures. However, the current IP, who has been in the position since December 2023, had only completed 15 out of the 23 required modules of the CDC's Nursing Home Infection Preventionist Training. During an interview, the IP acknowledged the incomplete training and the need to finish the remaining modules and posttest to obtain the certification. The facility provided documentation of the completed modules, confirming the deficiency in the IP's training.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide the required written bed hold policy to residents and their representatives within 24 hours of transfer to a hospital, as mandated by regulations. This deficiency was identified for two residents, R50 and R60, during a review of their records. For R50, the medical records indicated multiple hospitalizations on specific dates, yet there was no documentation that the bed hold policy was communicated to R50 or their family. The facility administrator confirmed that the policy was not sent or discussed with R50 or their family during these hospitalizations. Similarly, for R60, the resident census record showed several hospital transfers in 2024, but the facility failed to provide the bed hold notices for any of these transfers. The resident, R60, stated they did not recall receiving a bed hold form upon discharge to the hospital, and the administrator confirmed that R60 did not receive a bed hold notice during these transfers. This lack of communication regarding the bed hold policy constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Document Resting Hand Splint in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident requiring a resting hand splint. The resident's current orders specified a schedule for wearing the left upper extremity resting hand splint, which included wearing it two hours prior to each meal and at night, with removal during hygiene, bathing, and feeding. The orders also instructed discontinuation and contacting therapy if red or white spots appeared. However, during observations on two separate occasions, the resident's hand splint was found sitting on a shelf in her room, indicating non-compliance with the prescribed schedule. Additionally, the resident's care plan did not document the use of the resting hand splint, as confirmed by the Registered Nurse/Care Plan Coordinator.
Failure to Update Dialysis Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, R13 and R50, who were undergoing dialysis treatment. R13's care plan was not updated to reflect the discontinuation of an AV fistula and the placement of a new central dialysis port in the right chest. The care plan also lacked specific dialysis orders, such as the type of dialyzer, flow rate, length of time, target weights, and emergency contact information. Additionally, there was no assessment or care plan for the new dialysis port. This oversight was confirmed by the Registered Nurse/Care Plan Coordinator, who acknowledged that the care plan needed updating. Similarly, R50's care plan was not revised to document the presence of a dialysis catheter in the left upper inner thigh, as per the physician's orders. The care plan failed to include monitoring instructions for the catheter site, such as checking for bleeding and signs of infection. This deficiency was confirmed by both the Registered Nurse/Care Plan Coordinator and the Licensed Practical Nurse/Restorative Nurse, who noted the absence of documentation regarding the dialysis catheter in R50's care plan.
Failure to Follow Catheter Flush Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding the flushing of an indwelling urinary catheter for a resident, leading to a deficiency in care. The resident, who has a history of diabetes mellitus with chronic diabetic kidney disease, chronic kidney disease, and urinary tract infections, was supposed to have their catheter flushed daily with acetic acid and normal saline, as well as on an as-needed basis for increased sediment or blockage. However, the Medication Administration Record (MAR) indicated that the resident only received flushes on an as-needed basis, contrary to the physician's orders. On one occasion, a registered nurse (RN) discovered that the resident had no urine output and the urine in the catheter tubing was mucusy, milky, and amber-colored, which was unusual for the resident. The RN proceeded to flush the catheter and perform a bladder scan, which showed no urine in the bladder, indicating a possible blockage. The previous shift's licensed practical nurse (LPN) had noted low urine output but did not take action to flush the catheter or document the urine output, which contributed to the oversight. Additionally, there was confusion regarding the resident's orders, as a nurse practitioner reportedly changed the flush orders to as-needed only, but there was no documentation or recollection of this change by the nurse practitioner. The director of nursing stated that it was up to the nurse's discretion to flush the catheter based on urine appearance, but the RN's actions were deemed appropriate given the circumstances. The lack of documentation and communication among staff members led to the failure to provide appropriate care as per the resident's care plan.
Failure to Apply Resting Hand Splint for Resident
Penalty
Summary
The facility failed to apply a resting hand splint for a resident, identified as R65, who was reviewed for devices. The facility's Splint-Brace Assistance policy, reviewed on June 24, states that when splints and other contracture devices are part of the plan, therapy will instruct nursing staff on their use and recommend a schedule for applying and removing the device. R65's current orders for August 2024 specify a schedule for wearing the left upper extremity resting hand splint (RHS) two hours prior to each meal and at night, with specific instructions to discontinue use if red or white spots are present. However, there was no documentation in R65's treatment record or CNA charting regarding the application of the resting hand splint. Observations on August 27 and August 29 revealed that R65 was in bed without the resting hand splint, which was found on a shelf in her room. During an interview, R65 expressed discomfort with the trough, stating it pinched her arm and was not helpful. A CNA, identified as V12, was unfamiliar with R65's arm splints and referred to the nurse. An LPN, identified as V7, acknowledged that R65 did not like wearing the trough due to discomfort but was unaware of the hand splint. The physical therapist, identified as V14, confirmed that R65 should be using both the trough and resting hand splint as ordered.
Lack of Specific Dialysis Orders for Residents
Penalty
Summary
The facility failed to provide specific dialysis orders for two residents, R13 and R50, who required dialysis services. R13, diagnosed with end-stage renal disease and dependent on renal dialysis, was observed with a right chest long central catheter port wrapped in gauze. Despite attending dialysis five days a week, R13's medical record lacked specific dialysis orders, including the type of dialyzer, flow rate, length of time, target weights, and care of the dialysis port. A Licensed Practical Nurse (LPN) confirmed that the communication form from dialysis did not include specifics on the dialysate or target weight, and care of the dialysis port was managed by the dialysis center. Registered Nurses (RNs) on the dialysis unit, contracted by the facility, stated that the facility did not have access to specific resident orders for dialysis. Similarly, R50's physician orders documented dialysis five times a week but lacked an individualized dialysis prescription. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that specific individualized dialysis orders were kept in the dialysis unit, as they administered the dialysis. Facility orders for dialysis patients were generic, with additional orders to monitor sites and vital signs post-treatment. The RN mentioned that dialysis communication sheets were sent with the patient to dialysis and returned with documentation from the dialysis center.
Failure to Document and Offer Pneumonia Vaccinations
Penalty
Summary
The facility failed to document pneumonia vaccination records and offer pneumonia vaccinations to two residents out of a sample of five reviewed for pneumonia vaccinations. The facility's policy, revised in July 2022, mandates offering influenza and pneumococcal vaccinations to all residents upon admission unless prior immunization is reported. However, for one resident, there was no documentation of receiving or being offered the pneumonia vaccine upon admission. It was only after the surveyor's intervention that the resident was offered the vaccine and agreed to receive it at a future clinic. Similarly, another resident's record lacked documentation of being offered the pneumonia vaccine upon admission. After the surveyor's inquiry, the resident was offered the vaccine but declined. The Infection Preventionist acknowledged missing the immunizations on admission and confirmed that neither resident had prior vaccinations when asked later.
Failure to Document and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to properly document COVID-19 vaccination records and offer vaccinations to certain residents, leading to a deficiency. Specifically, three residents, identified as R13, R61, and R65, were not documented as having received or been offered the COVID-19 vaccine upon their admission to the facility. This oversight was discovered during a survey, prompting the Infection Preventionist (IP), identified as V4, to retrospectively document the vaccination status of these residents. For resident R13, there was no initial documentation of a COVID-19 vaccine offer or administration. After the surveyor's inquiry, V4 recorded that R13 was offered the vaccine and agreed to receive it at a future clinic. Similarly, residents R61 and R65 had no initial documentation regarding their vaccination status. Upon follow-up, V4 documented that both residents declined the vaccine, with R61 expressing disbelief in the vaccine. V4 acknowledged missing the opportunity to document their immunization status upon admission and confirmed that a vaccination clinic was scheduled for a later date.
Failure to Immediately Report Verbal Abuse Allegations
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was immediately reported to the Administrator, as required by their Abuse Prevention Guidance Policy. The policy mandates that employees report any incident, allegation, or suspicion of abuse to the administrator immediately. In this case, a Certified Nursing Assistant (CNA), identified as V12, reported hearing another CNA, V5, verbally abuse a resident, R4, by calling them derogatory names. However, V12 did not report this incident immediately to the Administrator, V1, but instead mentioned it to the former Director of Nursing, V2, and the Assistant Director of Nursing, V3, a few days later. This delay in reporting was a violation of the facility's policy. Further investigation revealed that other staff members, including V18, V22, and V23, also witnessed similar incidents of verbal abuse by V5 towards R4 but failed to report them immediately. V18 admitted to hearing V5 make derogatory comments about R4 several months prior but did not report it until much later. The resident, R4, was described as being very hard of hearing and confused, which may have impacted their awareness of the abuse. At the time of the survey, R4 appeared well-cared for and was not in distress, but the failure to report the abuse allegations promptly constituted a deficiency in the facility's adherence to its abuse prevention policy.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rock Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Manor | 0.8 mi | ★★★★★ | 2 | 0 |
| St Anthony's Nsg & Rehab Ctr | 1.4 mi | ★★★★★ | 6 | 0 |
| Allure Of The Quad Cities | 2.3 mi | ★★★★★ | 11 | 1 |
| Harmony Davenport | 3.7 mi | ★★★★★ | 14 | 0 |
| Ivy At Davenport | 4 mi | ★★★★★ | 26 | 2 |
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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 July 2026) and official state health department websites.