Arcadia Retirement Residence

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's privacy and dignity were maintained for one of two residents. The deficient practice compromised Resident (R) 36's privacy and dignity. Findings Include:Review of the facility reported incident (Intake #2636069) received on 10/04/25, documented that a Certified Nurse Aide (CNA) reported a video was taken on 09/30/25 during evening shift using the facility's cell phone. The video depicted R36 during peri-care with a heavily soiled incontinence brief. R36 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, dysphagia, obstructive sleep apnea, hemiplegia/hemiparesis due to cerebral infarction, Diabetes type 2, mild cognitive impairment, and epilepsy. [...]

Inspectors wroteBased on observations and staff interview, the facility did not follow proper sanitation practices in the kitchen. As a result of this deficiency, there was an increase risk for foodborne illness and an increase risk for hazards such as a fire.

Inspectors wroteBased on interview and record review, the facility failed to provide information of the risks and benefits of using psychotropic medications to three out of five sampled residents (Resident (R) 29, R63, and R46). This deficient practice has the potential to negatively affect the residents wellbeing and has the potential to affect all the residents in the facility on psychotropic medications. Findings Include: 1) R29 is an [AGE] year-old male admitted to the facility on [DATE]. R29 has a medical history that includes, but not limited to, dementia with psychotic disturbance, Parkinson's disease, and generalized anxiety disorder. On 10/03/24, a review of R29's Electronic Health Record (EHR) noted that R29 had a medication order for antidepressant since 05/30/24. [...]

Inspectors wroteBased on record review, staff interview and review of policy on Advance Health Care Directives (AHCD), the facility failed to ensure that the code status was consistent with the AHCD for one Resident (R)51 of two residents sampled. As a result of this deficient practice, there was the potential for R51 to receive unnecessary Cardiopulmonary Resuscitation (CPR).

Inspectors wroteBased on record review and interview, the facility failed to revise one of 18 sampled residents (Resident (R) 63) care plan after she sustained two falls. This deficient practice places R63 at risk for future falls and may affect all the residents in the facility who have fallen. Findings Include: A review of R63's Electronic Health Record (EHR) was conducted on 10/02/24. R63's EHR noted that she had a fall on 07/26/24 and 09/03/24. A review of R63's care plan did not contain new interventions that were implemented after her fall on 07/26/24 and 09/03/24. Interview was conducted with the Director of Nursing (DON) on 10/04/24 at 08:23 AM in his office. DON reviewed R63's care plan and confirmed that new interventions should have been placed in the care plan after R63's two falls. A review of the facility policy titled, Falls, dated 02/08/24 was conducted on 10/03/24. [...]

Inspectors wroteBased on observations, record review and interview the facility failed to correctly identify on Resident (R)13's Care Plan (CP) that she would be residing with her husband in a shared room. The deficient practice could affect all residents in the facility who are residing in a shared room with their husband or wife if they are not correctly identified as so. Findings Include: On 10/01/24 at 11:14 AM observed R46 sleeping in his bed and observed R13 resting in her bed in the shared room, each on their own side of the room. On 10/02/24 at 11:25 AM while observing lunch delivery to resident rooms observed R46 in his bed resting and R13 in her bed resting in their shared room. During record review on 10/04/24 found R13 had a CP with a Psychosocial Management/ Well-being problem with the following Resident is pleasant and easy to engage into conversation. [...]

Inspectors wroteBased on observations, staff interview and review of policy, the facility failed to secure an electrical panel on the third-floor nursing unit. As a result of this deficiency, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards.

Inspectors wroteBased on interviews and document and medical record review (RR), the facility failed to honor the rights of one Resident (R)1 of a sample size of three. Although R1 and a Family Member (FM)1 verbalized to nursing staff they did not want melatonin (sleep aid) administered, the staff did not honor that request, or follow up with the provider to discontinue the medication in a timely manner. As a result of this deficient practice, R1 continued to receive the melatonin, and R1 and FM1 were not included in the treatment plan after expressing concern. This could affect any resident and has the potential to be a barrier for them to obtain their highest level of psychological well being.

Inspectors wroteBased on interviews, document and record review, the facility grievance policy did not include the necessary requirements of 1) how to file a grievance anonymously, 2) identify and communicate who the grievance official was or how to contact, 3) did not determine a reasonable timeframe that complainant could expect a completed review of the grievance, 4) that they have the right to obtain the review in writing, or 5) ensure written grievance decisions meet documentation requirements. In addition, the facility failed to identify a concern verbalized by one Resident's (R)1 Family Member (FM)1, as a grievance, did not investigate the concern timely or keep FM1 apprised of the resolution. As a result of this deficiency, FM1 did not get the results of the investigation regarding all concerns. [...]

Inspectors wroteBased on interview and document review, the facility failed to report an alleged abuse to proper authorities within prescribed timeframe's. Specifically, the facility staff became aware of an alleged abuse on 07/31/2024 and did not report it to Adult Protective Services (APS) until 08/05/2024. In addition, the facility did not report the incident to the Office of Healthcare Assurance (OHCA) until 08/12/2024.

Inspectors wroteBased on interviews, document review and medical record review (RR), the facility failed to promptly notify the ordering physician of significant radiology findings. One Resident's (R)2 repeat chest xray findings showed significant changes from the previous xray taken three days earlier, and were not communicated to the physician for approximately one hour after the radiologist recorded the interpretation. In addition, the facility does not have a policy/procedure or effective process in place to identify which imaging results should be called to provider. This deficient practice has the potential to affect all residents and may result in adverse outcomes.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure pain management was provided to the resident according to the resident's goals and preferences. R7 reported lumbar pain which impeded the resident from using the Hoyer lift to get out of bed for showers and/or socializing with staff and/or other residents. R7 reported receiving Lidocaine patches and Tylenol as the current plan for pain management, however, the medications are ineffective. R7 reported increased feeling of depression and being worn down by constant, unrelieved pain, and the inability to get out of bed. R7 goal and preferences for pain management is to be able to use the Hoyer lift, increased sleep, and minimal severe pain. [...]

Inspectors wrote2) While conducting an interview with Resident (R)29 on 10/31/23 at 11:05 PM, the resident reported staff being very loud and waking up the resident, daily, when they come into the room at 04:30 AM to assist the resident's roommate to the bathroom. R29 confirmed she wants to sleep in and does not want to be awaken by staff at that hour. During an interview with the Director of Nursing (DON) and an Advising DON (AADON) on 11/03/23 at 10:19 AM, the DON confirmed staff should minimize the sound level to avoid disturbing resident's sleep. Based on observations and staff interview, the facility failed to maintain a safe, homelike environment as evidenced by two different areas of the building being in disrepair and staff not maintaining comfortable sound levels.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident's right to a dignified existence for two residents sampled. As a result of this deficient practice, residents are at risk for more than minimal harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident representative's right to make decisions on behalf of the resident for one resident (Resident (R)70) sampled. As a result of this deficient practice, there is a potential risk of more than minimal harm.

Inspectors wroteBased on observations and interviews, the facility failed to provide reasonable accommodation of resident's needs to one out of 21 sampled residents (Resident (R) 21). This failed practice has the potential to affect all the residents in the facility. Findings Include: R21 is a [AGE] year-old male admitted to the facility on [DATE]. R21 is currently receiving hospice care in the facility. Concurrent observation and Interview were conducted on 11/01/23 at 10:17 AM in R21's room. R21 stated that he is constantly requesting for more water, and it takes telling two or three staff until someone finally provides him with more. The resident has two small cups on his bedside table. One cup was filled halfway with water and the other cup was filled with clear light brown liquid. Resident's water pitcher was located on top of the bedside dresser, which is located behind the resident. [...]

Inspectors wroteBased on interviews and record review, the facility failed to immediately consult with the resident's physician after a resident fell and had the potential for requiring physician interventions for one resident (Resident (R)70) sampled. R70 fell and sustained multiple bruises and reported hitting her head, was on medications which inhibit the resident's blood clotting abilities (Aspirin and Xarelto) placing the resident at higher risk for internal bleeding, and the physician was not notified until 1 hour and 40-minutes after the resident fell. Facility staff reported R70's physician is regularly difficult to contact. As a result of this deficient practice, all residents under the same care of R70's primary physician is at risk for potential of harm.

Inspectors wroteBased on interviews and record review, the facility failed to assure that two sampled residents (Resident (R)72 and R70 ) received an accurate assessment, reflective of the residents' status at the time of the assessment. This deficient practice places all the facility residents at risk for assessment inaccuracy. Findings Include: 1) A review was conducted of R72's Electronic Health Record (EHR). R72's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/28/23 indicated that R72 had three stage two pressure ulcers that were not present upon admission. Interview was conducted on 11/02/23 at 08:09 AM with R72 in the dining room. R72 stated that he had the pressure ulcer before admission to the facility. Interview was conducted with Director of Nursing (DON) on 11/03/23 at 10:26 AM. DON stated that R72's pressure ulcers were present during admission and was miscoded on the MDS. [...]

Inspectors wroteBased on record review (RR) and staff interview the facility failed to include R12's choices for her advanced healthcare directives in her baseline care plan. The deficient practice could affect any newly admitted resident at the facility. Findings Include: On 11/02/2023 at 01:21 PM RR did not find a signed Baseline Care Plan form for R12. On 11/02/2023 at 04:33 PM medical records was able to provide a copy of the baseline care plan for R12. Baseline care plan was signed by staff completing the baseline care plan on 09/29/2023 for R12 who was admitted that day. Noted the Advanced Directives/Code Status section was left blank. On 11/03/2023 at 11:41 AM reviewed R12's baseline care plan with Interim DON who stated the Advanced Directives/Code Status section is to be filled out, this area was left blank. [...]

Inspectors wroteBased on observation, record review (RR) and resident interview the facility failed to include use of a walker in Resident (R)35's comprehensive care plan and use of antidepressant in R12's comprehensive care plan. The deficient practice could affect any resident at the facility. Findings Include: 1. On 10/31/2023 at 09:29 AM met and spoke with R35 in her room. R35 asked surveyor if I saw her walker on the other side and she pointed towards the partition in her room. Looked on other side of partition but saw a walker that was in the living space of R35's roommate. R35 stated a facility staff, nurse, had told her she could not use her walker. Inquired if R35 had fallen and she denied falling in the facility. R35 stated she walked in the hallway yesterday with the therapist and she took the walker away. [...]

Inspectors wroteBased on interviews and record review, the facility failed to revise Resident (R)70's comprehensive care plan (CCP). R70 fell on [DATE] and sustained bruising to the right forearm, abdomen, left breast, and a lump on the forehead and is on daily scheduled medications which increases the resident's risk for bleeding and bruising. The resident's fall care plan was not revised after the fall and injuries sustained on 10/08/23 to include the risk for increased injury or additional monitoring related to the medication. As a result of this deficient practice, residents on anticoagulant/antiplatelet medication increases the severity of injury residents could sustain during a fall.

Inspectors wroteBased on observation and staff interview the facility failed to assure a medication cart was locked when not being used by a nurse. The deficient practice could affect all residents, staff and visitors who could have access to the unlocked medication cart. Findings Include: On 11/02/2023 at 02:17 PM while standing in the hallway near the nurse's station on the second floor noticed a registered nurse (RN)5 walk away from the medication cart which she left unlocked. Surveyor remained with medication cart till RN5 returned. During this time the Interim DON came by and was shown the medication cart was left unlocked and unattended. On 11/02/2023 at 02:24 PM RN5 returned to unlocked medication cart. RN5 confirmed the med cart is supposed to be locked when it is left unattended. [...]

Inspectors wroteBased on record review (RR) and staff interview the facility failed to maintain an accurate medical record for R59 putting her at risk for a fall from a bed that was care planned to Do not not leave bed on lowest position. This deficient practice could affect all residents at the facility who have an impaired mobility. Findings Include: 1. During RR of R59's care plan noted under Impaired Mobility/Falls an intervention listed stated Maintain fall precautions. Adjust height of bed to comfortable height for easy in/out of bed. Do not leave bed on lowest position. On 11/02/2023 at 02:01 PM met with Interim DON and looked at R59's bed. R59 was sleeping in her bed and facility staff showed the bed was at it's lowest position. R59's bed was a regular hospital bed and not a low to the ground bed. Interim DON stated it appears to be an error in the care plan, regarding the height of the bed.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper glove use procedures were followed by a staff member. This deficient practice places the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: Concurrent observation and interview were conducted on 11/02/23 at 02:05 PM. Housekeeper (HK) 1 was observed entering the second floor through the stairwell access with gloves on. HK1 then entered the laundry room and immediately exited. Infection Control Coordinator (ICC) was present in the laundry room. When ICC was queried about HK1's glove use, ICC stated that HK1 should not have gloves on in the hallway.

Inspectors wroteBased on observations, record review, and interviews with staff members, the facility failed to 1) Ensure appropriate alert mechanisms on exit doors were functional on the nursing units after one resident (R)52, was able to elope from the facility. This deficient practice could have potentially placed any residents who wander in immediate danger and 2) Failed to implement interventions, including adequate supervision to prevent an avoidable fall for 1 out of 2 residents Resident (R)47 sampled for falls. As a result, R47 sustained a fracture to left ribs. Findings Include: 1) On 12/19/22 at 10:33 AM, observed R52 walking out of his room. R52 was observed to be walking up and down the hallway with a steady gait before lunchtime. On 12/20/22 at 09:57 AM, R52 ' s family member (FM) was interviewed via phone. [...]

Inspectors wroteBased on observations, review of the facility's policy and procedures, and interview with staff member, the facility failed to ensure that all foods were procured, stored, prepared, distributed, and served under sanitary conditions. Observations of a refrigerator found temperatures greater than 41 degrees Fahrenheit (F); and stored food items were not covered. Findings Include: During the initial kitchen tour observation with Head [NAME] on 12/19/22 at 08:15 AM, observed trays of raw chicken located in the walk in refrigerator on a tray cart uncovered. The plastic that was on top of the tray cart was not completely over the cart. Head [NAME] acknowledged it should be covered. Further concurrent observation with Head [NAME] during the initial kitchen tour on 12/19/22 at 08:21 AM, a refrigerator inside thermometer measured 46 degrees F and the exterior thermometer measured 51 degrees F. [...]

Inspectors wroteBased on observations and interview with staff member, the facility failed to ensure the dishwasher was maintained in safe operating condition. The facility did not ensure proper temperatures of the dishwasher was achieved. Findings Include: During the initial kitchen tour with Head [NAME] on 12/19/22 at 08:15 AM, Head [NAME] stated the facility's dishwasher used heat to sanitize the dishes and the final rinse thermometer should reach 180 degrees Fahrenheit (F). Observed a dish test tray going through the dishwasher. Observed the final rinse thermometer not reaching appropriate temperature. The thermometer for the rinse function did not reach 180 degrees F minimum as instructed on the dishwasher. Kitchen Aide (KA) 2 confirmed the rinse function did not reach 180 degrees F. A second observation of a test tray was done and the dishwasher final rinse thermometer reached 180 degrees F. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to appropriately manage inappropriate temperatures for two of its two medication refrigerators. This deficient practice has the potential to risk spoilage of necessary medications for residents, such as insulin and vaccines, and could result in serious and harmful outcomes.

Inspectors wroteBased on record review and interview with staff members, the facility did not assure Resident (R) 26's advance health care directive (AHCD) was documented and filed in the resident's medical record. The facility failed to ensure R26 was periodically given opportunities to formulate an AHCD. This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes. Findings Include: R26 was admitted to the facility on [DATE]. Record review found a checklist documenting R26 formulated an AHCD but no AHCD was found on file in the resident's medical record. On 12/20/22 at 10:35 AM interview with Social Worker (SW) was done. SW confirmed the facility does not have R26's AHCD on file. SW stated R26's family members reported R26 has an AHCD but has not provided a copy to the facility. [...]

Inspectors wroteBased on observation, staff interview, record review and review of policy, the facility failed to provide a safe, clean environment for one Resident (R)32 of eight residents sampled. As a result of this failure, R32 had a prolonged exposure to mold and was put at risk for developing adverse reactions.

Inspectors wroteBased on observations, record review, and interview with staff members, the facility failed to ensure Resident (R) 47 was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms, as evidenced by R47's posey belt, used for safety, placed behind her where she is unable to reach and remove herself. The deficient practice has the potential to affect all residents at the facility from ensuring they are free from physical restraints not required to treat medical symptoms. Findings Include: R47 was admitted to the facility on [DATE] with diagnoses not limited to age-related osteoporosis, anemia, cognitive communication deficit, depression, history of falling, abnormalities of gait and mobility, and dementia. [...]

Inspectors wroteBased on record review and interview with staff members, the facility failed to immediately report an injury of unknown source to the adult protective services (APS) in accordance with State Law for Resident (R) 44 after fracture results of R44's right foot. Findings Include: R44 was admitted to the facility on [DATE] with diagnoses not limited to dementia, Parkinson's disease, rheumatoid arthritis, and age-related osteoporosis. Review of R44's quarterly Minimum Data Set (MDS) with an assessment reference date of 10/04/22, R44's Brief Interview Mental Status (BIMS) scored him at a 3 (severe cognitive impact). In Section G. Functional Status, under Transfers (how resident moves between surface including to and from bed, chair, wheelchair, standing position), R44 requires extensive assistance with two-person physical assist. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that one resident's (R) comprehensive care plan goals were communicated to the receiving health care provider to ensure a safe and effective transition of care. R22 needed to be transferred to a hospital for higher level of care and could potentially be sub optimally cared for because her individualized care plan and goals were not communicated to the receiving facility. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on record reviews and interviews, the facility did not provide written information about their bed hold policy to one resident (R), R22, who needed a higher level of care and was transferred to a hospital. The facility does not have a current bed-hold policy for residents who are hospitalized which leaves the resident with no possible bed to return to when their acute medical condition has resolved. This has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, record review and interview with staff members, the facility failed to implement one of 18 sampled residents Resident (R) 47 person-centered comprehensive care plan. An intervention to prevent injury for R47 with a history of falls was not implemented. Findings Include: R47 was admitted to the facility on [DATE] with diagnoses not limited to age-related osteoporosis, anemia, cognitive communication deficit, depression, history of falling, abnormalities of gait and mobility, and dementia. While admitted to the facility R47 had a total of four falls, on 06/25/22, 07/10/22, 08/04/22 and 11/01/22. Review of R47's clinical notes documents R47 had an unwitnessed fall in her room on 11/01/22 and had a X-Ray to right elbow on 11/02/22 with impression of acute displaced fracture of the olecranon (a long bone in the forearm that projects behind the elbow). [...]

Inspectors wroteBased on observations and interview the facility failed to update the nurse staffing data daily and at the beginning of each shift for one of four units. Findings Include: On 12/19/22 at 10:45 AM on the third floor, observed the daily nurse staffing data posted at the front of the nurse's station dated 12/19/22 with the total number of licensed and unlicensed nursing staff and hours worked for night shift. Day shift and evening shift were observed to be blank. On 12/19/22 at 11:00 AM concurrent observation and interview with Infection Preventionist (IP) and Registered Nurse (RN) 12 was done. IP confirmed the daily nurse staffing data for day shift was not filled out and day shift starts at 08:00 AM. RN12 stated day shift did not start until 10:00 AM today because she did not come in until 10:00 AM. IP and RN12 confirmed the time this observation and interview took place was 11:00 AM. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to adhere to COVID-19 infection control protocol by not appropriately disinfecting and changing personal protective equipment (PPE) after exiting from one resident's (R), R25's COVID-19 isolation room, out of a sample of one resident. This deficient practice encourages the transmission of the COVID-19 virus which has the potential to affect all residents, staff, and visitors in the facility.