Arcadia Care Jacksonville

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order for a STAT x-ray and failed to notify the physician of inability to follow the physician's STAT order for one or three residents (R5) reviewed for post fall assessment and treatment in the sample list of 14. This failure resulted in a delay in diagnostic evaluation and treatment of a fracture causing undo pain. Findings Include:R5's face sheet documents an admission date of 07/25/2018 with diagnoses including: Schizophrenia Unspecified, Other Lack of Coordination, Vitamin D Deficiency and Cognitive Communication Deficit. R5's nursing progress note dated 3/20/2026 at 6:09PM written by V10 (Licensed Practical Nurse/LPN) documents that R5 sustained a fall on 3/20/2026 at 3:30pm and complained of pain at a 5 out of 10 with no new skin concerns. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident for three (R1, R2, R4) of three residents reviewed for abuse in the sample list of 14.

Inspectors wroteBased on interview and record review, the Facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 63 residents living in the Facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store medication and discard expired medication. This failure has the potential to affect all 63 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure foods were properly stored, labeled, dated, and discarded when expired in accordance with sanitary food services practices. This failure has the potential to affect all 63 residents receiving meals prepared by the dietary department. Findings Include:On 3/1/26 at 8:15 AM, during the initial kitchen tour, the surveyor observed concerns related to improper food storage. Observation of the large double-door refrigerator revealed the following expired food items:A one (1) gallon container of salad dressing, approximately 1/4 full, with an expiration date of 2/2025.3 large bags of lettuce noted to be wilted with an expiration date of 2/26/26. A one (1) gallon container of sweet pickle relish, approximately 1/4 full, with an expiration date of 12/18/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to answer call lights timely and sit down beside residents when providing assistance with eating for 5 of 6 residents (R19, R24, R20, R41, R50) reviewed for dignity in the sample of 38.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident call lights were within reach for 4 of 6 residents (R9, R26, R29, R50) reviewed for call lights in the sample of 38. Findings Include:1. R9's admission Record print date of 3/5/26 documents R9 has diagnoses including transient cerebral ischemic attack, COPD (chronic obstructive pulmonary disease), asthma, type 2 diabetes mellitus with diabetic neuropathy, idiopathic peripheral autonomic neuropathy, non-pressure chronic ulcer of unspecified part of right lower leg, non-pressure chronic ulcer of right heel and midfoot, and atrial fibrillation. R9's MDS (Minimum Data Set) dated 1/28/26 documents R9 is severely cognitively impaired and dependent on staff for mobility. R9's undated Care Plan documents ensure call light is in reach. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and needs of residents during evenings and every other weekend for 5 of 5 residents (R10, R19, R20, R52, and R62) reviewed for activities in the sample of 38. Findings Include:1. On 3/1/26 at 2:45 PM observed R62 pacing and walking in circles in the hallway. Did not observe any activities going on throughout the day. R62's admission Record with a print date of 3/3/26 documents R62 has diagnoses of Asperger's syndrome and autistic disorder. 2. On 3/2/26 at 11:40 AM R19 stated the facility has not had activities every other weekend for a long time because the company cut the budget. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to label oxygen tubing for 4 of 6 residents (R29, R56, R57, and R58) reviewed for oxygen therapy in the sample of 38.

Inspectors wroteBased on interview and record review the facility failed to provide mail to residents every Saturday for 2 of 5 residents (R19 and R20) reviewed for resident rights in the sample of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required assistance received necessary activities of daily living (ADL) care, including nail care, grooming services, and proper positioning and assistance for meals. This resulted in a resident having visibly dirty hair and fingernails, being unshaven, and at risk for aspiration due to improper positioning during a meal for 2 of 6 residents (R9, R14) reviewed for ADL care in the sample of 38. Findings Include:1. On 03/01/2026 11:30AM lunch being provided was baked turkey with gravy, scalloped potatoes, sauteed cabbage, orange slices and roll. On 3/1/2026 at 11:48AM R14 was seen wandering up and down the hall. V3, Certified Nursing Assistant (CNA) was prompting R14 to come into the dining room and eat. R14 was walking away from table not eating or sitting down. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care in accordance with professional standards by failing to maintain ordered wound dressings and by failing to identify and treat new wounds for 3 of 3 residents (R1, R9, R50) reviewed for wounds in the sample of 38. Findings Include:1. R9's admission Record print date of 3/5/26 documents R9 has diagnoses including transient cerebral ischemic attack, COPD (chronic obstructive pulmonary disease), asthma, type 2 diabetes mellitus with diabetic neuropathy, idiopathic peripheral autonomic neuropathy, non-pressure chronic ulcer of unspecified part of right lower leg, non-pressure chronic ulcer of right heel and midfoot, and atrial fibrillation. R9's MDS (Minimum Data Set) dated 1/28/26 documents R9 is severely cognitively impaired and dependent on staff for mobility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide proper assistance with ambulation and transfers for 2 of 4 residents (R24 and R43) reviewed for accidents in the sample of 38.

Inspectors wroteBased on interview, observation, and record review, the facility failed to coordinate services for a neurology consult for abnormal movements, falls and a gagging incident for 1 of 16 residents (R30) reviewed for quality of care in the sample of 35. This failure resulted in R30 having increased involuntary movements that resulted in worsening involuntary movements.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a Registered Nurse (RN) 8 hours a day, seven days a week for 18 of 18 days reviewed for RN coverage from 11/1/2024-11/18/2024. This failure has the potential to effect all 75 residents at the facility.

Inspectors wroteBased on interview and record review the facility failed to provide 12 hours of Certified Nursing Assistant (CNA) training on a yearly basis for 3 of 5 CNA's (V13, V31 and V36) reviewed for training. This failure has the potential to affect all 75 residents residing at the facility.

Inspectors wroteBased on record review and interview, the facility failed to notify residents and representatives, in writing, prior to being transferred to the hospital, for 6 of 6 (R7, R12, R17, R36, R54, R72) residents reviewed for discharge transfer notice requirements in a sample of 35.

Inspectors wroteBased on interview, observation, and record review, the facility failed to perform hand hygiene, change gloves when soiled, wear Personal Protective Equipment, and sanitize a multi-use blood glucose monitor to prevent cross contamination for 10 of 16 residents (R1, R4, R16, R20, R22, R24, R31, R57, R61, R71) reviewed for infection control in the sample of 35.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed accommodate a resident's preference to eat in his room for 1 of 5 residents, (R8), reviewed for Resident's Rights in a sample of 35.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to report changes in condition to the physician for 1 out of 2 residents, (R30), reviewed for notification of changes in a sample of 35. 1. R30's admission record, print date of 11/21/24, documents that R30 was admitted on [DATE] and has diagnoses of Psychosis, Schizoaffective Disorder, Drug Induce Subacute Dyskinesia, and Schizophrenia. R30's Minimum Data Set, dated [DATE], documents that R30 is severely cognitively impaired, requires setup or clean up assistance for eating, supervision or touching assistance for sitting and walking. On 11/18/24 at 3:58 PM, R30 is in the hallway walking. R30 has very spastic jerky movements of the arms, legs, head, tongue, and mouth. R30 has involuntary backward arching of the back, shuffling of the feet sidewise and forward motion. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for 1 of 3 residents (R52) reviewed for abuse in the sample of 35.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to protect a resident while smoking for 1 out of 1 residents, (R8), reviewed for smoking safety and accident prevention in a sample of 35.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide complete incontinent care for 3 of 7 residents (R16, R31, R43) reviewed for incontinent care in the sample of 35.

Inspectors wroteBased on interview, observation, and record review, the facility failed to recognize a nonfunctioning Gastrostomy tube for 1 of 4 residents (R16) reviewed for Gastrostomy tube in the sample of 35.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide medications as the Physician Ordered. There were 37 opportunities with 6 errors resulting in a 16.22% medication error rate. The errors affected 2 residents (R70 and R44).

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide diets as ordered by the physician for 1 of 16 residents (R30) reviewed for quality of care in the sample of 35.

Inspectors wroteBased on interview, observation and record review, the facility failed to promote residents' dignity by addressing residents' needs timely for 4 of 5 residents (R2, R3, R4, R5) reviewed for dignity in the sample of 5. This failure resulted in R2 feeling humiliated after having to urinate in her water pitcher due to staff not assisting her.

Inspectors wroteBased on interview, observation, and record review, the facility failed to wear personal protective equipment (PPE) to prevent the potential spread of COVID-19. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain an effective call system to ensure residents can communicate to staff when they need assistance. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to employ a Registered Nurse, (RN), for eight hours per day. This failure has the potential to affect all 73-resident residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a medication error rate of less than 5% when 2 medications were unavailable, and 6 medications were administered incorrectly to 2 of 5 residents (R6, R7). This resulted in 8 medication errors out of 31 opportunities resulting in a medication error rate of 25.80%.

Inspectors wroteBased on interview, observation and record review, the facility failed to complete wound care as ordered and document wound descriptions/observations in 2 of 3 residents (R1, R2) reviewed for wound care in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was treated with dignity by ensuring privacy when urinating and allowing residents to eat at same time as other residents for 4 of 4 residents (R10, R16, R63, R70) observed for dignity in the sample of 46. This failure resulted in R16 feeling frustrated and sitting hungry awaiting his food for an hour after meal service.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there were sufficient nursing staff in the facility to provide adequate care and assistance for residents including assistance with bathing. This failure has the potential to affect all 77 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the water temperature of the dish machine was hot enough to sanitize the dishes to prevent food borne illness. This failure has the potential to affect all 77 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fly infestation through effective pest control. This has the potential to affect all 77 residents who reside in the building. 1. R16's Minimum Data Set (MDS), dated [DATE], documents that R16 is cognitively intact. On 11/5/2023 at 9:21 AM there were multiple flies on R16's heavily soiled dressing on right foot. A fly was on top of urine filled urinal and 1 fly floating in urine. 1 fly was on R16's arm. On 11/5/2023 at 9:39 AM R16 stated that the flies are bad. R16 stated that he doesn't have anything to kill them with. R16 stated that he does not like it and would rather not have them at all. On 11/6/2023 at 10:22 AM, R16 was lying in bed with 2 flies on R16 and flying around R16's feet and 1 fly on R16's arm. On 11/7/2023 at 12:42 PM R16 was lying in bed with flies on the bed and on R16's body. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent resident-to-resident physical abuse for 4 of 24 residents (R2, R26, R45, R179) reviewed for abuse in the sample of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents with incontinent care, bathing, grooming, hygiene, change of clothing, and eating assistance for residents who require assistance for 4 of 23 residents (R38, R63, R64, R69) reviewed for assistance with Activities of Daily Living (ADL) care in the sample of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to provide complete and timely incontinent care for 5 of 5 residents (R4, R17, R18, R33, R63) reviewed for incontinent care in a sample of 46.

Inspectors wroteBased on observation, interview, and record review, provide gastrostomy tube (g-tube) feedings according to the facility policy, including correct resident positioning, and checking for placement and/or residual prior to administering tube feedings to the resident for 4 of 4 residents (R4, R18, R22, R70) reviewed for gastrostomy tube feedings in the sample of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication and label insulin for 4 of 5 residents (R14, R25, R34, R72) reviewed for medication labeling and storage in a sample of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform appropriate hand hygiene, glove changes when soiled, and to ensure the wound care supplies were kept clean to prevent contamination and potential infection for 4 of 23 residents (R4, R16, R17, R63) reviewed for infection control in a sample of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove breakfast meals from the rooms timely for 4 of 4 residents (R17, R38, R68, R279) reviewed for room cleanliness and homelike environment in the sample of 46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a palatable meal served at palatable temperatures for 13 of 13 residents (R2, R5, R8, R10, R11, R16, R24, R32, R41, R43, R53, R62, R71) reviewed for palatable food in the sample of 46.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clean shower rooms for 4 of 7 residents (R1, R2, R6, R7) reviewed for clean homelike environment in the sample of 7.