Arcadia Care Auburn

Inspectors wroteBased on record review and interview the facility failed to administer the correct medication to 1 of 3 residents (R12) reviewed for medication errors in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to answer call lights and provide care in a timely manner for 2 (R1, R2) of 4 residents reviewed for resident rights in a sample of 4. 1.) R1's admission Record documents R1 was admitted to the facility on [DATE] and has a diagnosis of Epilepsy, Parkinson's Disease without Dyskinesia, Essential Tremor, Chronic Obstructive Pulmonary Disease, Fibromyalgia, Chronic Kidney Disease, Lack of Coordination, Generalized Anxiety Disorder, Hypothyroidism, and Major Depressive Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, is dependent on staff for toileting hygiene, showering/bating, and needs substantial/maximal assistance for personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure room temperatures were within the heat index/apparent temperature guidelines inside the facility and did not exceed 81 degrees Fahrenheit (F), the Facility failed to follow their Heat Emergency Policy as residents were not moved out of their rooms when temperatures were reached over 81 degrees for 4 of 4 residents (R1, R2, R3 and R11) reviewed for room temperatures in the sample of 16. This failure resulted in residents being left in rooms with the heat index indicating extreme caution to the residents. On 8/27/2025 at 9:55 AM, the Immediate Jeopardy/IJ was called with V1, Administrator. V2, Director of Nursing. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer medication as ordered for 1 of 3 residents (R2) reviewed for medication in the sample of 5.

Inspectors wroteBased on observation and interview the facility failed to provide comfortable temperatures in the dining room and visiting room. This failure has the potential to affect all 57 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide hot water for resident use for 21 of 21 residents (R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, R26) reviewed for safe/comfortable/homelike environment in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a hot water heater to supply hot water to residents for 16 days for 21 of 21 resident (R1, R2, R3, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R23, R24, R25, R26) reviewed for Physical Environment in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to monitor and track, infections in the facility for 5 of 5 (R3, R8, R47, R30, and R22) residents reviewed for antibiotic stewardship/ Infection control in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse for 3 of 5 residents (R24, R36, R109) reviewed for abuse in the sample of 34. Findings Include: R20's Face Sheet, undated, documents R20 has the following diagnoses: Anxiety Disorder, Depression and Unspecified Dementia with Behavioral Disturbance. R20's Minimum Data Set, MDS, dated [DATE], documents R20 has severe cognitive impairment and displays verbal, physical, and other behaviors. R20's Care Plan, dated 3/29/23, documents R20 has a behavior problem of becoming physically aggressive towards others, becoming aggressive when anxious becoming verbally aggressive and has a mood problem. R20's Progress Note, dated 7/16/24 at 4:40 PM, documents the following: R20 grabbed another resident (R109) by the right arm, shirt area. No signs of injury noted. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide surgical site care on 1 of 3 residents (R257), reviewed for quality of care in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to administer anti-hypertensive/cardiac medications at safe intervals of time for 2 of 3 residents (R2, R3) reviewed for medications errors in the sample of 4.

Inspectors wroteBased on interviews and record review the facility failed to implement interventions, for R2 to prevent overdose of medication. Faculty was aware R2 had medications in her purse and previously had meds. R2 was being seen by a Psychiatry Nurse Practitioner. R2 had shown a decrease in Mental status and the Psychiatry Nurse Practitioner, nor the Physician was notified. Based on interviews and record review the facility failed to accurately assess, monitor, implement and provide services, for R2's Mental and Psychosocial wellbeing, due to R2 recently sustaining physical abuse, and having major depressive disorder and anxiety. This resulted in R2 overdosing on Xanax and Tylenol. Then being admitted to hospital and subsequently expiring. The Immediate Jeopardy began on 04/18/2024 when R2 was admitted to facility, with known history of spousal abuse, depression, and anxiety. [...]

Inspectors wroteBased on interviews and record review the facility failed to implement interventions, for R2 to prevent overdose of medication. Faculty was aware R2 had medication previously and that she had medications in her purse. R2 was being seen by a Psychiatry Nurse Practitioner. R2 had shown a decrease in Mental status and the Psychiatry Nurse Practitioner, nor the Physician was notified. This failure of not reporting or calling the Physician or Psychiatry Nurse Practitioner and R2 having meds in her purse, resulted in R2 overdosing, being sent to the Hospital and Expiring. R2 admit date to facility on 4/18/2024, with diagnoses of Parkinson's Disease, Encounter for Mental Health Services for Victim of Spousal or Partner abuse, Depression, unspecified, and Generalized Anxiety Disorder. [...]

Inspectors wroteBased on interview and record review the Facility failed to provide a RN (Registered Nurse) 8 hours a day 7 days a week. This has the potential to affect all 59 residents of the facility.

Inspectors wroteBased on interviews and record review the facility failed to notify family/Power of Attorney (POA) of a fall and fully discuss residents declining medical condition with POA for POA to make decisions on resident's medical treatment options for one of three residents (R2) reviewed for notification in the sample of 8. This failure resulted in no discussion of possible Hospice treatment to address R2's overall decline in health and ongoing pain.

Inspectors wroteBased on interviews and record review the facility failed to provide vascular consult timely for one of three residents (R2) reviewed for quality of care in the sample of 8. This failure resulted in R2 experiencing a decrease in circulation to R2's lower extremities, increased pain, and discomfort in R2's lower extremities and hospitalization for septic shock related to decreased circulation and gangrene.

Inspectors wroteBased on observation, interview and record review the facility failed to provide complete incontinent care for 1 of 4 residents (R1) reviewed for incontinent care in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to provide hand hygiene per current standards of practice during incontinent care for 2 of 3 residents, (R1, R4) reviewed for infection control practices during urinary and bowel incontinent care in the sample of 35.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide a physician prescribed narcotic to relieve pain for 1 of 5 residents (R8) reviewed for pain in the sample of 8. This failure left R8 without moderate pain medication from 11/17/23 - 11/20/23 while in the facility for rehabilitation from a broken hip.

Inspectors wroteBased on interview, observation and record review, the facility failed to follow physician's orders for 3 of 3 residents (R1, R3, R8) reviewed for wound treatments in the sample of 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care to promote healing and the prevent deterioration of Moisture Associated Dermatitis for 2 of 16 residents (R5, R26) reviewed for quality of care in the sample of 37. This failure resulted in the worsening of R26's Moisture Dermatitis.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely and complete incontinence and catheter care for 5 of 5 residents (R5, R8, R16, R26, R206) reviewed for incontinent care in the sample of 37. This failure resulted in R206 feeling demeaned and experiencing pain during incontinent care.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 52 residents living in the Facility. Findings Include: The Facility's documentation for CNA (Certified Nurse Aide), RN (Registered Nurse), and LPN (Licensed Practical Nurse) staff numbers, hours scheduled, and hours worked was provided for 10/12/22 through 10/26/22. These document the Facility did not have a RN for eight consecutive hours on 10/12/22, 10/15/22, 10/17/22, 10/18/22, 10/19/22, 10/20/22, 10/21/22, 10/22/22, 10/23/22, and 10/24/22. On 10/27/22 at 8:35 AM, V1, Administrator, stated, We have had trouble with RN staffing. We had a full time, part time, and PRN (as needed), and they all left around the same time. It has been hard finding new nurses. I don't think we have a policy for RN staffing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication, and label a Tuberculin (TB) vial. This has the potential to affect all 52 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 52 residents living in the Facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to develop an ongoing infection control program that adequately collects data to tract/trend infections to prevent outbreaks, perform hand hygiene before and after glove changes and to properly clean the glucometer used by residents. This has the potential to affect all 52 residents living in the Facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to maintain safe and palatable food temperatures for 4 of 4 residents (R10, R13, R25, R44) reviewed for food palatability in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to establish an antibiotic stewardship program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 6 residents (R32, R35, R48, and R256) reviewed for antibiotic stewardship in the sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to ensure there is completed documentation of residents' influenza and pneumococcal vaccine administration and/or refusal for 5 of 6 residents (R24, R25, R33, R44, and R206) reviewed for influenza and pneumococcal immunizations in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with hygiene and grooming for residents needing assistance with personal care for 1 of 4 residents (R43) reviewed for Activity of Daily Living (ADL) care in a sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat pressure ulcers per physician's orders and failed to provide turning and repositioning to prevent the worsening of pressure ulcers for 2 of 3 residents (R13 and R48) reviewed for pressure ulcers in the sample of 37.

Inspectors wroteBased on interview, observation and record review, the facility failed to administer medications as prescribed. There were 26 opportunities with 3 errors resulting in a 11.54% medication error rate. The error involved 1 resident (R22) in the sample of 37 out of 6 residents observed during medication administration.