Arcadia Care Morris

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to safely meet the residents' care needs. This applies to 3 of 8 residents (R2, R7, R10) reviewed for staffing in a sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for residents who require assistance with activities of daily living (ADL) care. This applies to 5 of 5 residents (R10, R21, R31, R32, R33) reviewed for nail care in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that indwelling urinary catheter and perineum care were provided in a manner that would prevent urinary tract infection (UTI). This applies to 4 of 4 residents (R10, R11, R15, R21) reviewed for catheter and perineum care in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving, placement of urinary drainage bag, soiled linen and clothes, and not wearing complete personal protective equipment (PPE) when providing care for residents under enhance barrier precautions (EBP). This applies to 10 of 10 residents (R1, R7, R10, R11, R12, R13, R15, R21, R28, R29) reviewed for infection control in the sample of 37.

Inspectors wroteBased on observations and interviews, the facility failed to provide residents with a clean and sanitary environment. This applies to 3 of 5 residents (R8, R12, R25) reviewed for Physical Environment in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide skin treatment/dressing change according to physician order for a resident who was identified with skin breakdown. This applies to 1 of 4 residents (R10) reviewed for wound treatment in the sample of 37.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide sufficient staffing in accordance with its facility assessment tool and residents' care needs. This applies to 3 of 3 (R1, R31, R34) residents reviewed for sufficient staffing in a sample of 37.

Inspectors wroteBased on the interview and record review, the facility failed to provide a resident with the daily cost of services no longer covered by Medicare in order for resident to make an informed decision whether they wish to continue receiving skilled services that may not be covered by Medicare and to assume financial responsibility. This applies to 1 of 4 residents (R4) reviewed for Resident Rights in a sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify physicians of a resident's elevated Lithium level. This resulted in staff's continued administration of Lithium to the residents resulting in a resident's hospitalization with primary diagnosis of Lithium toxicity. The facility also failed to notify physicians and family members of a resident's injury (bruise) after an unwitnessed fall. This applies to 2 of the 6 residents (R1 and R5) reviewed for notification of change in condition and incident/accident in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and address a resident (R1) who was having a change in condition. The facility also failed to do a complete follow up (post-fall) body assessment for a resident (R5) who had a fall incident. This failure resulted in a resident (R1) being lethargic throughout the morning shift until the early evening shift without appropriate intervention and was later hospitalized with a primary diagnosis of Lithium toxicity. This applies to 2 of 6 residents (R1 and R5) reviewed for change in condition and accident in the sample of 9.

Inspectors wroteBased on observations, interviews, and record review the facility fail to revise and implement care plan interventions to prevent falls and provide safety for a resident identified as risks for falls. This applies to 1 (R47) of 3 residents reviewed for safety and supervision in the sample of 20.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident's social security benefits from previous facility were transferred over and processed to the resident's present facility as representative payee of the resident's personal needs allowance (PNA). This applies to 1 of 3 residents (R1) reviewed for personal needs allowance (PNA) in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to obtain orders and administer medications as prescribed. This applies to 1 of 3 (R1) resident reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene and follow enhanced barrier precautions. This applies to 3 of 3 (R6, R7 and R12) residents reviewed for infection control in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their water management plan for legionella. The facility also failed to follow their policy for enhanced barrier precautions, transmission based precautions, and hand hygiene during provisions of care. This applies to all 72 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 7 of 8 residents (R3, R8, R12, R30, R44, R63 and R67) reviewed for ADLs (activities of daily living) in the sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve mechanical soft consistency mushrooms and potatoes and failed to serve pureed consistency chicken and vegetables for residents on mechanical soft and pureed diets. This applies to 9 of 9 residents (R1, R6, R10, R15, R24, R26, R30, R41 and R224) reviewed for mechanically altered diets in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to a resident's call for help and failed to ensure that the call light was always within reach of the resident. This applies to 1 of 18 residents (R12) reviewed for call light accessibility in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide splints to a resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 4 residents (R63) reviewed for range of motion in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that urinary catheter tubing and bag are always below a resident's bladder to prevent potential urine backflow. This applies to 1 of 2 residents (R3) reviewed for catheter care in the sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide breakfast meals for a resident who is on dialysis treatment. This applies to 1 of 2 residents (R41) reviewed for dialysis in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents central line insertion sites were visible under a transparent dressing for assessment. The facility also failed to ensure that the central line dressings were clean and intact. This applies to 2 of 2 residents (R124 and R174) reviewed for IV (intravenous) central line in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident did not receive antipsychotic medications without indications for use. This applies to 1 of 5 residents (R43) reviewed for psychotropic medications in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to identify a pressure injury before becoming unstageable and failed to provide treatment to moisture associated dermatitis. These failures resulted in R4 developing an unstageable pressure injury to the sacrum. This applies to 1 of 4 residents (R4) reviewed for pressure injuries in the sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor residents at risk for weight loss, offer nutritional supplements as ordered by the physician in order to prevent additional weight loss, and offer food substitutes for meals/snacks that were refused to prevent unplanned weight loss and maintain resident nutritional status. This failure resulted in R40 experiencing a 29.29% weight loss within 4 months of admission. This applies to 2 residents (R40 and R43) reviewed for weight loss in a sample of 31.

Inspectors wroteBased on interviews and record reviews, the facility failed to have a full time RN (Registered Nurse) as the facility's DON (Director of Nursing). This affects all 81 residents at the facility reviewed for staffing. The 12/5/23 CMS-671 form showed 81 residents live in the building. On 12/07/23 at 4:24 PM, V2 DON said, I am an LPN (Licensed Practical Nurse) full time. I am the only DON. V2 said the facility knew that the DON is supposed to be an RN. V2 said that she has been the DON since July of 2023. V2 said that I have been the DON and V21 (Operations Consultant), the administrator at that time, told me he knew that the DON needs to be an RN, but he put me in the position anyway. On 12/07/23 at 4:13 PM, V1 (Administrator) said he did not know if V2 was an RN or not. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to serve food in a sanitary manner. This applies to all 81 residents reviewed for sanitary food storage and preparation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents receive regular bathing, grooming and assistance with activities of daily living. This failure applies to 6 residents. (R18, R38, R43, R56, R64 and R68) in the sample of 31 residents reviewed for assistance with activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store active medications safely and discard outdated medications. This applies to 3 of 5 residents (R7, R15, and R62) reviewed for medication storage in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain temperature logs and label food items in residents' personal refrigerators and failed to discard outdated food items. This applies to 6 of 6 residents (R24, R26, R47, R52, R64 and R184) reviewed for personal food storage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medication and obtain a physician order for resident medication to be at the bedside. This applies to 1 resident (R62) reviewed for medication self-administration in the sample of 31.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assist in the application of ordered braces. The facility failed to assist with clothing changes. This applies to one resident (R26) reviewed for brace use in a sample of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to prepare foods to residents' liking. This applies to 3 residents (R40, R77, and R185) out of 32 residents reviewed for meal satisfaction. 1. On 12/5/23 at 12:18 PM, R40 said she can't stand the food. R40 said the French fries are cold and hash browns are limp and cold. R40's POS (Physician Order Sheet) shows she is on a no added salt diet. R40's MDS (Minimum Data Set) dated 11/14/23 shows her cognition is intact. R40's Care Plan dated 11/20/23 shows R40 is at increased nutritional risk related to anemia and hypertension. Interventions include, prepare and serve diet as ordered. 2. On 12/5/23 at 12:31 PM, R77 said the food is a concern, she can't eat it and it is always cold. R77's POS shows she is on a no added salt diet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure supervision to prevent falls with injury for 1 resident (R45), failed to provide ambulation assistance for 1 resident (R61), and failed to implement updated fall prevention measures for a resident following a fall with a fracture for 1 resident (R2). These failures apply to 3 of 4 residents reviewed for safety and supervision. These failures resulted in R45 having 15 unwitnessed falls with 3 of those falls resulting in major injury and R2 sustaining a hip fracture.

Inspectors wroteBased on interview and record review the facility failed to ensure pain medications were available to a resident for 1 of 1 resident (R39) reviewed for pain in the sample of 22. This failure resulted in R39 experiencing sleeplessness and narcotic medication withdrawal symptoms.

Inspectors wroteDeficiency resulted in two deficient practice statements. 1. Based on observation, interview, and record review the facility failed to ensure a dishwasher temperature reached manufacturer's guidelines and failed to ensure foods and fluids were covered during transport to the residents' rooms. These failures have the potential to affect all 84 residents residing in the facility. 2. Based on observation, interview, and record review the facility failed to ensure the kitchen floor was maintained in a sanitary condition. This failure has the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents dependent upon staff for bathing received scheduled showers for 4 of 5 residents (R5, R15, R28, R35) reviewed for activities of daily living in the sample of 22.

Inspectors wroteBased on interview and record review the facility failed to ensure food was served at a palatable temperature for 4 of 4 residents (R28, R32, R35, R39) reviewed for food in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's chosen advanced directive was in place for 1 of 1 resident (R35) reviewed for advanced directives in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate a dermatology referral per physician recommendation for 1 of 2 residents (R52) reviewed for quality of care in the sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to position a resident's (R73) urinary catheter drainage bag in a manner to prevent urinary tract infections for 1 of 1 resident reviewed for catheter care in the sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's peripheral intravenous (IV) line was inserted in a manner to prevent infection. This failure applies to 1 of 2 residents (R70) reviewed for IV line insertion in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident received oxygen as ordered by a physician for 2 residents (R78, R68) and failed to ensure respiratory equipment was stored in a manner to prevent contamination for 1 resident (R11). These failures apply to 3 of 4 residents reviewed for oxygen therapy in the sample of 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor two residents (R56, R61) receiving antipsychotics for side effects and behaviors, failed to identify a medically diagnosed condition for a resident (R56) receiving an antipsychotic. These failures apply to 2 of 5 residents reviewed for psychotropic medications in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering a COVID-19 isolation room for 2 of 3 residents (R34 and R135) reviewed for infection control in the sample of 22.