Arcadia Care Rock Island
2545 24th Street, Rock Island, IL 61201 · Rock Island County · 177 certified beds · avg 66 residents/day · certified since Jun 19, 1997
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: ★★☆☆☆2/5 · 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, repeated · Aug 28, 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 (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 29, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jul 22, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Jul 31, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 22, 2025 · 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: Jul 31, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (30)
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 |
|---|---|---|
| Mar 23, 2026 | D · Potential for harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Oct 28, 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. · from a complaint |
| Sep 21, 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 |
| Aug 28, 2025 | ▲ K · Immediate jeopardy, repeated | 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 |
| Aug 28, 2025 | F · Potential for harm, facility-wide | The facility has more than 120 beds but did not hire a qualified full-time social worker as required. · from a complaint |
| Aug 2, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Aug 2, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Aug 2, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Aug 2, 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. · from a complaint |
| Jul 22, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 22, 2025 | ▲ 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 |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 30, 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. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Jun 26, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 31, 2024 | 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 |
| Sep 19, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 13, 2023 | E · Potential for harm, repeated | 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. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Jul 13, 2023 | D · Potential for harm, one-off | 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. |
| Feb 10, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 10, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Feb 10, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | E |
| 2024 | 10 | 0 | D |
| 2025 | 10 | 3 | K ▲ |
| 2026 | 1 | 0 | D |
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)
3 fines totaling $68,777, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jul 22, 2025 | Fine | $10,358 |
| Jul 22, 2025 | Fine | $14,069 |
| Jul 22, 2025 | Fine | $44,350 |
| Jul 22, 2025 | Payment Denial | 20 days from Aug 15, 2025 |
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) | 3.14 | 2.99 | 3.95 | top 28% in Illinois; bottom 19% in the U.S. |
| Registered Nurse hours | 0.39 | 0.63 | 0.69 | bottom 31% in Illinois; bottom 21% in the U.S. |
| Weekend total nurse staffing | 2.64 | 2.67 | 3.50 | top 35% in Illinois; bottom 14% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.29 | 0.56 | 0.48 | bottom 19% in Illinois; bottom 30% in the U.S. |
| Total nursing staff turnover (%) | 46.4 | 44.5 | 45.8 | bottom 43% in Illinois; bottom 46% in the U.S. |
| RN turnover (%) | 54.5 | 41.8 | 42.9 | bottom 29% in Illinois; bottom 29% 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 4.05, RN 0.50, weekend 3.41. 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: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Barrish Group Limited Partnership | Organization | 5% or Greater Direct Ownership Interest | 9% | 08/26/2008 |
| Barrish, Bryan | Individual | 5% or Greater Direct Ownership Interest | 9% | 07/22/2008 |
| Gesualdo, Mary | Individual | 5% or Greater Direct Ownership Interest | 9% | 01/01/2021 |
| Gesualdo, Ralph | Individual | 5% or Greater Direct Ownership Interest | 9% | 07/22/2008 |
| Winter, Thomas | Individual | 5% or Greater Direct Ownership Interest | 6% | 07/22/2008 |
| Behrens, Amie | Individual | W-2 Managing Employee | NOT APPLICABLE | 08/17/2021 |
| Bergthold, Louise | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2009 |
| Generations HC Network | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/22/2008 |
| Winter, Thomas | Individual | Corporate Officer | NOT APPLICABLE | 07/22/2008 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "Do you have a full-time social worker on staff, and how would they work with my family member?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "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 |
|---|---|---|---|---|---|
| Friendship Manor | 0.8 mi | Rock Island, IL | ★★★☆☆ | 4/5 | |
| St Anthony's Nsg & Rehab Ctr | 1.4 mi | Rock Island, IL | ★☆☆☆☆ | 1/5 | |
| Allure of the Quad Cities | 2.3 mi | Moline, IL | ★☆☆☆☆ | 1/5 | abuse |
| Harmony Davenport | 3.7 mi | Davenport, IA | ★★☆☆☆ | 2/5 | |
| Ivy at Davenport | 4.0 mi | Davenport, IA | ★☆☆☆☆ | 1/5 | SFF |
| Good Samaritan - Davenport | 4.1 mi | Davenport, IA | ★★★☆☆ | 3/5 | |
| The Vistas at Bettendorf | 4.6 mi | Bettendorf, IA | ★★★☆☆ | 3/5 | |
| Ridgecrest Village | 5.5 mi | Davenport, IA | ★☆☆☆☆ | 1/5 | abuse |
| Hope Creek Nursing & Rehab | 5.8 mi | East Moline, IL | ★☆☆☆☆ | 1/5 | abuse |
| Allure of Moline | 6.0 mi | East Moline, IL | ★☆☆☆☆ | 2/5 | abuse |
| Davenport Lutheran Home | 6.3 mi | Davenport, IA | ★★☆☆☆ | 2/5 | |
| Harmony Utica Ridge | 6.3 mi | Davenport, IA | ★★☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145950.