Arcadia Care Toulon

Inspectors wroteBased on record review and interview the facility failed to ensure ceiling tiles and a cold water pipe were kept clean, in good repair, and free of leaks. These failures have the potential to affect all 72 residents residing within the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure all Certified Nurse Aides (CNAs) received the 12 hours of required annual competency in-service training. This failure has the potential to affect all 72 residents who currently reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure all Certified Nurse Aides received behavioral health training. This failure has the potential to affect all 72 residents who currently reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a fall intervention for one of three residents (R3) reviewed for falls in the sample of nine.

Inspectors wroteBased on observation, interview and record review the Facility failed to provide a functional, safe and comfortable environment for Residents and the public. This failure has the potential to affect all 71 Residents residing in the Facility.

Inspectors wroteBased on observation, interview and record review the Facility failed to provide proper nourishment of normal meal hours for five of nine Residents (R13, R14, R15, R16 and R17) reviewed for mealtime in a sample of 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 21 residents (R10) was free from involuntary seclusion, failed to ensure criteria was met for admission to the Secured Dementia Unit and failed to follow physician's guidance for resident's wellbeing to prevent a change in condition reviewed in a sample of 41. These failures resulted in R10, a cognitively intact resident with admitting diagnoses of Post-Traumatic Stress Disorder and Generalized Anxiety, to be admitted to the Secured Dementia Unit on 1/30/26 and remained in the unit until 2/26/26. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on 1/30/26, when the facility failed to ensure a resident was free from Involuntary Seclusion when a cognitively intact resident was placed in a Secured Dementia Unit preventing the resident from leaving. [...]

Inspectors wrote:Based on observation, interview and record review, the facility failed to provide adequate administrative oversight to ensure the facility implemented their policies for protecting resident's dignity, be free of involuntary seclusion and restraints, accurately assessed residents and provided quality of care based on those assessments, services were provided to meet professional standards, ADL (Activities of Daily Living) cares were provided for dependent residents, medications were safely administered, infection prevention measures were implemented and appropriately utilized, staff were qualified and competent and maintained a safe/ clean/comfortable environment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's change in condition and ensure diagnostic tests were completed as ordered for one of two residents (R1) with a change in condition, in a sample of 41. This failure resulted in R1 being transferred to the hospital with a diagnosis of RSV (Respiratory Syncytial Virus)

Inspectors wroteBased on record review and interview, the facility failed to ensure that nursing staff (Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants) were competent to perform their job duties as evidenced by the facility's lack of education, in-service, and competency assessment records. This failure has the potential to affect all 67 residents residing within the facility.

Inspectors wroteBased on observation interview and record review, the facility failed to monitor stored fresh produce and destroy spoiled produce stored in the kitchen's walk-in refrigerator. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly contain garbage and refuse in the facility's dumpsters. This failure has the potential to affect all 67 residents residing in the facility posing the risk of attracting insects, pests and rodents to the facility.

Inspectors wroteThese failures resulted in two deficient practices. A. Based on interview, observation and record review, the facility failed to ensure residents and staff were monitored and tracked for communicable diseases and ensure a process to prevent the spread of diseases to other residents and staff. The facility also failed to wear masks properly while in close proximity to residents. These failures have the potential to affect all 67 residents who currently reside in the facility. B. Based on observations, interview and record review, the facility failed to wear appropriate PPE (Personal Protective Equipment) for Enhanced Barrier Precautions and failed to perform hand hygiene for four of twenty-four residents (R2, R5, R27, R60) reviewed for Infection Control, in a sample of forty-one. The facility's Daily Census Report, dated 2/24/26, documents 67 residents reside in the facility. A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain or repair residents' missing and peeling wall coverings and exposed dry wall for 8 residents (R13, R16, R31, R39, R42, R44, R62, R69), and failed to repair the wall area between the HVAC/heating, ventilation, air-conditioning unit and the window sill for two residents (R30, R37) in the total sample of 41 residents reviewed for clean, comfortable and homelike environments. This failure has to potential to affect all 67 residents living in the facility

Inspectors wroteBased on record review and interview, the facility failed to ensure all staff received mandatory training and education for infection prevention and control. This failure has the potential to affect all 67 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure all staff were provided education, in-services, and training regarding the facility's standards, policies, and procedures for Compliance and Ethics. This failure has the potential to affect all 67 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) were provided and completed a minimum of 12 hours of inservice training per year. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a Pneumococcal Immunization to two residents (R1, R60) that requested to receive it and failed to offer a Pneumococcal Immunization to three (R13, R52, R55) residents out of 8 residents reviewed for immunizations, in a sample of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to treat three residents (R5, R27,R76) with dignity in three reviewed for dignity in a total sample of 41.1. R5's medical record documents R5 was admitted to the facility on [DATE] with diagnoses to include Spina Bifida, Paraplegia, Chronic Obstructive Pulmonary Disorder, Hydronephrosis, and Urinary Retention. On 2/25/26 at 2:15 PM, V11 (Certified Nurse Aide/CNA) and V16 (CNA) transferred R5 via mechanical lift from his wheelchair to his bed. R5's privacy curtain was not pulled prior to V11 and V16 pulling down his pants and incontinent brief to prepare him for catheter procedure. V18 (Licensed Practical Nurse/LPN) entered room and pulled the privacy curtain between R5 and his roommate. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's toileting preferences and needs were reasonably accommodated for one of one resident (R51) reviewed for accommodation of needs in a sample of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment for four of 24 residents (R1, R48, R58, R60) reviewed for a homelike environment in a sample of 41. These failures have the potential to affect all 67 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 1 resident (R9) reviewed for physical restraints was free from physical restraint, in a sample of 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to have appropriate indications for use for psychotropic medications for three of five residents (R6, R7, R11) reviewed for unnecessary medications in a sample of forty-one.

Inspectors wroteBased on record review and interview, the facility failed to document discharge status for one resident of two residents (R71) reviewed for discharge in a sample of forty-one.

Inspectors wroteBased on interview and record review, the facility failed to update a care plan after an incident for one resident of twenty-four residents (R7) reviewed for care plans in a total sample of forty-one.

Inspectors wroteBased on record review and interview, the facility failed to have supporting documentation for diagnosis for two of twenty-four residents (R10, R11) reviewed for justified diagnoses, in a total sample of forty-one.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist and provide showers for three of twenty-four residents (R6, R43, R48) reviewed for showers, in a total sample of forty-one.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, develop and implement a care plan and provide an ongoing program of activities based on residents' assessments and preferences for 2 of 4 residents (R51, R11) reviewed for activities in a sample of 41.

Inspectors wroteBased on interview and record review, the facility failed to do a urinary voiding trial as ordered for one of four residents (R8) reviewed for indwelling catheters, in a total sample of forty-one.

Inspectors wroteBased on record reviews, interviews and observation, the facility failed to ensure oxygen tubing was changed routinely for one of one resident (R55) reviewed for respiratory care, in a sample of 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were safely administered for one of seven residents (R48) observed during the medication administration pass, in a sample of 41.

Inspectors wroteBased on interview and record review the facility failed to prevent a resident from physical abuse by another resident for one (R3) of 5 residents reviewed for physical abuse by another resident in the sample of 8 residents reviewed for abuse. This failure has the potential to affect all 18 residents currently living in the Memory Care Unit on E Hall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from abuse when R2 was deprived of utilizing a jacket for one of three residents (R2), reviewed for abuse in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was immediately reported to the Administrator and the State Agency for one of three residents (R2) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of potential abuse for one of three residents (R2) reviewed for abuse, in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to use a full mechanical lift for 3 (R1, R4, R5) residents who require a full mechanical lift for transfers in a sample of 22.

Inspectors wroteBased on interview and record review the facility failed to thoroughly assess and document an accurate assessment for one resident (R1) transferred to the emergency room of three residents reviewed for hospitalizations in a total sample of thirteen. Findings Include: The Facility's Assessment of Resident policy dated 10/2024 documents the purpose of the policy is to gather comprehensive information as a basis for identifying resident problems/needs and developing or revising an individual plan of care. The policy also documents begin assessment based on resident position. Conduct head to toe examination on admission incidents, and significant status changes and periodically as necessary. Conduct specific system assessment, as required by the diagnosis, history or physical complaint. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have fall interventions in place for one resident (R3) of three residents reviewed for falls in a total sample of thirteen. Findings Include: The Facility's Fall Prevention Program dated 5/2022 documents the purpose as to assure the safety of all residents in facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. R3's Nurse's Notes dated 5/8/25 at 10:30 AM documents The CNA (Certified Nurse Aide) observed (R3) sitting half upright onto the buttock, near the bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two cognitively impaired residents (R1, R8) who were at risk for abuse; and failed to prevent resident to resident physical abuse by two cognitively impaired residents (R2, R9). This failure affected 4 of 4 residents (R1, R2, R8 & R9) reviewed for abuse in a sample of 9. The failure resulted in R2 placing both of his hands around R1's neck and forcefully squeezing into R1's neck; and resulted in R8 being physically punched in the face with a closed fist by R9.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders by not obtaining a urine sample as ordered in a timely manner for one of three residents (R3) reviewed for nursing services in a sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent staff physical abuse for one resident (R1) of three residents reviewed for abuse in the sample of four.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident grievances are resolved in a timely manner. This failure has the potential to affect all 64 residents living in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse was scheduled for at least eight consecutive hours each day. This failure has the potential to affect all 64 residents living in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure residents were notified that signing an arbitration agreement was not a condition of admission and residents have 30 days to rescind the agreement within 30 days of signing. This failure has the potential to affect all 64 residents in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure the QAA/Quality Assessment and Assurance Committee had the required number of Members; failed to ensure the QAA Committee met at least quarterly; and failed to have reports submitted by Infection Preventionist. This failure has the potential to affect all 64 Residents residing at the facility. Findings Include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form dated 10/29/24 documents 64 residents reside in the facility. The facility's Quality Assurance Plan Dated 8/1/17 documents: (Facility) works to continuously improve the way residents are cared for, safety and operations within the facility through the Quality Assurance process. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an Antibiotic Stewardship Program to promote the appropriate use of antibiotics and include a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This failure has the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to designate an Infection Preventionist (IP) who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program and implement programs and activities to prevent and control infections. This has the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide influenza vaccine for residents eligible for influenza vaccination during flu season and failed to minimize the risk of acquiring, transmitting and suffering complications from influenza for five of five residents R14, R28, R33, R38, and R45 reviewed for immunizations in the total sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PASARR (Pre-admission Screening and Resident Review) screening was completed for one (R28) of five residents reviewed for PASARR screenings in the sample of 22. Findings Include: The Centers for Medicare and Medicaid Services/CMS National Report: A Review of Preadmission Screening and Resident Review (PASARR) Programs Dated 12/2019 documents: Preadmission Screening and Resident Review (PASARR) is a federal Medicaid requirement that mandates states operate programs designed to: (1) identify individuals who might be admitted to or reside in a nursing facility (NF) who have a serious mental illness (SMI), or an intellectual disability or a related condition (ID/RC); (2) consider both NF and community placements for such individuals and recommend NF placement only if appropriate; [...]

Inspectors wroteBased on record review, and interview, the facility failed to revise care plans for two residents (R2 and R55) of 16 residents reviewed for Care Plan revisions, in a total sample of 22 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for two of five residents (R6, R14) reviewed for unnecessary medications in the sample of 21.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure its enhanced barrier precautions policy was followed for two of two residents (R1, R24) reviewed for enhanced barrier precautions in a sample of 22.

Inspectors wroteBased on record review and interview, the facility failed to notify a physician per their facility policy of a medication error/omission for one resident (R1) of three residents reviewed for physician notification of changes in a total sample of three residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (R1) of three residents received prescribed medication for anxiety as per a physician order without significant error in a total sample of three resident reviewed for medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions once a resident was assessed as being at high risk of developing pressure ulcers, failed to assess a pressure ulcer's stage and size once identified, failed to perform daily skin checks as ordered by the physician, failed to perform physician ordered wound treatment, and failed to perform pressure ulcer risk assessments every week for four weeks after admission and quarterly thereafter, as instructed by the facility's policy, for one of three residents (R1) reviewed for pressure ulcers in the sample of five. These failures resulted in R1 developing a facility acquired stage three pressure ulcer to the right medial ankle.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's bed was kept in the lowest position, failed to keep resident personal items and call light within reach, failed to ensure a resident was secure while being transported in the facility van, failed to investigate a fall, failed to implement and revise fall interventions, and failed to update the fall care plan after a fall for one of three residents (R1) reviewed for falls with injuries in the sample of five. These failures resulted in R1 falling out of bed while reaching for his cell phone while his bed was in a high position, sustaining a left femur fracture, and R1 falling forward out of his wheelchair while being transported in the facility van causing R1 to experience neck and shoulder pain, fear, and emergency department treatment for pain.

Inspectors wroteBased on record review and interview the facility failed to accurately complete MDS (Minimum Data Set) Assessments for one of three residents (R1) reviewed for changes in condition in the sample of five.

Inspectors wroteBased on record review and interview the facility failed to ensure a staff member treated a resident with respect for one of three residents (R1) reviewed for resident rights in the sample of three.

Inspectors wroteBased on record review and interview, the facility failed to revise a Comprehensive Care Plan for one resident (R1) of three residents reviewed for Care Plan revision in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent a fall for one (R1) resident of three residents reviewed for accidents/supervision in a sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized rehabilitation services as ordered for three (R1, R2, R3) of six (R1-R6) reviewed for therapy services in the sample of six.

Inspectors wroteBased on interview and record review, the facility failed to have a complete record for five of six residents (R1, R3-R6) reviewed for specialized therapy in the sample of six.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate unwitnessed falls and adequately supervise a resident (R65) with a known history of wandering to prevent them from entering another resident's room (R60) startling her and causing a fall for two of two residents (R60, R65) reviewed for falls in the sample of 34. This failure resulted in R60 obtaining a hemorrhagic pelvic fracture.

Inspectors wroteBased on record review and interview the facility failed to ensure that a Registered Nurse was staffed a minimum of eight hours in a 24 hour period for 2 days of 10 reviewed for staffing. This has the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to label and date opened food items in the kitchen and ensure that kitchen equipment was clean and in working order. This has the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement in a manner that the resident and their representative understands and acknowledge if the resident and their representative understood the agreement. This had the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean comfortable homelike environment for two of two residents (R59, R79) reviewed for clean comfortable homelike conditions in the sample of 34.

Inspectors wroteBased on record review, interview and observation the facility failed to follow operational policies and procedures, notify the Abuse Coordinator of an injury of unknown origin, and to investigate an injury of unknown origin for one of one resident (R67) reviewed for injury of unknown origin in a sample of 34. Findings Include: The facility policy, named Abuse Prevention Program, revised 11/28/2016, documents, Supervisors shall immediately inform the administrator of all reports of mistreatment, exploitation, neglect and abuse of resident. Upon learning the report, the administrator or designee shall initiate an investigation. Anonymous reports will also be thoroughly investigated. R67's Skin Only Evaluation, dated 9/22/2023, documents Does (R67) have current skin issues: YES. Skin issue number one: scattered bruising to right arm. Skin Note: [...]

Inspectors wroteBased on interview, record review and observation, the facility failed to report the allegation of abuse for a bruise of unknown origin to the Abuse Coordinator/Administrator for one of one resident (R67) reviewed for abuse in a sample of 34. Findings Include: The facility policy, named Abuse Prevention Program, revised 11/28/2016, documents, Internal Reporting Requirements and Identification of Allegations: Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents or suspect to supervisor and the administrator. Supervisors shall immediately inform the administrator or his/her designated representative of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents. Nursing supervisor is responsible for reporting to the Administrator or designee. [...]

Inspectors wroteBased on record review, interview and observation the facility failed to investigate a bruise of unknown origin for one of one resident (R67) reviewed for injury of unknown origin in a sample of 34. Findings Include: The facility policy, named Abuse Prevention Program, revised 11/28/2016, documents, Supervisors shall immediately inform the administrator of all reports of mistreatment, exploitation, neglect and abuse of resident. Upon learning the report, the administrator or designee shall initiate an investigation. Anonymous reports will also be thoroughly investigation. (R67's) Skin Only Evaluation, dated 9/22/2023, documents, Does (R67) have current skin issues: YES. Skin issue number one: scattered bruising to right arm. Skin Note: (R67) woke up this morning with scattered bruises to her right arm and one on her right hand. Cause is unknown. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers to residents requiring assistance for one of one resident (R59) reviewed for ADLs (Activities of Daily Living) in the sample of 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a residents wound was treated timely and a physician ordered treatment order was put in place upon wound identification for one of two residents (R12) reviewed for wounds in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check a g-tube (gastrostomy tube) for residual or flush the g-tube with water prior to administering medications and failed to obtain a physician ordered water flush for prior to and after administering medications for one of one resident (R79) reviewed for g-tubes in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician ordered laboratory values for one of one resident (R59) reviewed for anticoagulant monitoring in the sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear gloves while directly handling medications and while administering gastrostomy tube medications for one of nine residents (R79) reviewed for medication administration in the sample of 34.