Arcadia Care on the Hill
555 West Carpenter, Springfield, IL 62702 · Sangamon County · 251 certified beds · avg 121 residents/day · certified since May 23, 1969
Part of chain: ARCADIA CARE (25 facilities, chain avg rating 1.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Sep 17, 2025 · F-0658 · triggered by a complaint
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Why it matters: Care that falls below professional standards can directly harm a resident's health and recovery.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Sep 18, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 17, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 15, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Aug 24, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 1, 2023 (Past Non-Compliance)
▲ Actual harm, one-off · Apr 22, 2026 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 1, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 17, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 28, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 16, 2024 · F-0690 · triggered by a complaint
The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 3, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 17, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 9, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 22, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 26, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 17, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 17, 2025 | ▲ L · Immediate jeopardy, facility-wide | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Sep 17, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Sep 17, 2025 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 17, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 17, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 17, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 17, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 17, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jun 24, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 5, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 29, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 24, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 24, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 24, 2024 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jul 24, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 16, 2024 | ▲ G · Actual harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Apr 1, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 17, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 17, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 17, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Sep 13, 2023 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 13, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 13, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 13, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Sep 13, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 24, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 1 | J ▲ |
| 2024 | 12 | 2 | G ▲ |
| 2025 | 12 | 3 | L ▲ |
| 2026 | 1 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
4 fines totaling $229,143, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Apr 22, 2026 | Fine | $73,800 |
| Sep 17, 2025 | Fine | $98,313 |
| Sep 17, 2025 | Payment Denial | 62 days from Oct 8, 2025 |
| Apr 1, 2024 | Fine | $47,515 |
| Aug 24, 2023 | Fine | $9,515 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.06 | 2.99 | 3.95 | bottom 11% in Illinois; bottom 1% in the U.S. |
| Registered Nurse hours | 0.13 | 0.63 | 0.69 | bottom 1% in Illinois; bottom 1% in the U.S. |
| Weekend total nurse staffing | 1.92 | 2.67 | 3.50 | bottom 15% in Illinois; bottom 1% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.07 | 0.56 | 0.48 | bottom 1% in Illinois; bottom 1% in the U.S. |
| Total nursing staff turnover (%) | 29.1 | 44.5 | 45.8 | top 14% in Illinois; top 13% in the U.S. |
| RN turnover (%) | 60.0 | 41.8 | 42.9 | bottom 21% in Illinois; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.80, RN 0.17, weekend 2.61. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 5/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| David a Berkowitz Delta Trust | Organization | Direct Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Seitler, Dovid | Individual | Direct Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| Yosef Meystel Delta Trust | Organization | Direct Ownership Interest | NOT APPLICABLE | 08/01/2024 |
| 555 W Carpenter Rd LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/28/2025 |
| Aci Equities, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Ahearn, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2024 |
| Ahearn, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Arcadia Care Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/2024 |
| Arcadia Care Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/28/2025 |
| Cooper, Brandy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2024 |
| Cooper, Brandy | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Frankel, Frederick | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 12/08/2025 |
| Goldfarb, Brian | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/16/2026 |
| Hti Investor Group, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Liddell, Jackie | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2024 |
| Liddell, Jackie | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| McClure, Michelle | Individual | Corporate Officer | NOT APPLICABLE | 08/01/2024 |
| McClure, Michelle | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2024 |
| McClure, Michelle | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Seitler, Dovid | Individual | Corporate Officer | NOT APPLICABLE | 08/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Regency Care | 1.5 mi | Springfield, IL | ★☆☆☆☆ | 2/5 | |
| Arc at Sangamon Valley | 2.9 mi | Springfield, IL | ★☆☆☆☆ | 1/5 | |
| Avenues at Springfield | 2.9 mi | Springfield, IL | ★★☆☆☆ | 3/5 | |
| Springfield Suites Rehab and Nursing | 3.1 mi | Springfield, IL | ★★★☆☆ | 3/5 | |
| Concordia Village Care Center | 4.5 mi | Springfield, IL | ★★★★★ | 4/5 | |
| Villa Health Care East | 6.9 mi | Sherman, IL | ★☆☆☆☆ | 2/5 | |
| Sunny Acres Nursing Home | 15.2 mi | Petersburg, IL | ★☆☆☆☆ | 1/5 | abuse |
| Arcadia Care Auburn | 15.3 mi | Auburn, IL | ★☆☆☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145160.