Arcadia Care Auburn

In the surveyor’s words

From the most serious findings on record at Arcadia Care Auburn, in the surveyor’s own words.

• Immediate jeopardy, widespreadF609May 4, 2023

  Based on interview and record review, the facility failed to report an allegation of abuse in 1 of 8 residents reviewed for abuse in the sample of 9. This failure resulted in the abuse of R2 due to the abuse on R1 not being reported, this subsequently allowed V2, Former Administrator to further abuse another resident. The Immediate Jeopardy began on 03/08/23 when R1 was swinging his cane and stating his was going to hit someone. V2 was asked by V11, Activity Director to assist with getting the cane from R1. V2 then twisted the cane out of R1's hands. V2 also placed his hands on R1's chest in an attempt to calm R1 while lying in his bed. V1 Administrator was notified of the Immediate Jeopardy on 05/02/2023 at 3:00 PM. […]

• Immediate jeopardy, widespreadF610May 4, 2023

  Based on interview and record review, the facility failed to investigate/prevent the abuse in 2 of 8 residents reviewed for abuse in the sample of 9. This failure resulted in R1 and R2 being abused by V2, Former Administrator. The Immediate Jeopardy began on 03/08/23 when the facility failed to prevent and protect the R1 and R2 from abuse and failed to report an allegation of abuse to prevent further abuse to the residents. V1 Administrator was notified of the Immediate Jeopardy on 05/02/2023 at 3:00 PM. The Surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 05/04/2023, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. […]

• Immediate jeopardy, patternF584Aug 27, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF678Feb 11, 2025

  Based on interview, observation, and record review the facility failed to act immediately after determining a resident was unresponsive, did not check for a pulse until prompted by the survey team and initiate CPR immediately to a resident in medical distress for 1 of 1 resident (R257) reviewed for CPR in the sample of 34. This failure resulted in an Immediate Jeopardy that began on [DATE] at 10:09AM, when R257 was identified to be unresponsive to verbal stimuli and staff failed to check for a pulse until prompted by the survey team and immediately initiate CPR (Cardiopulmonary Resuscitation). On [DATE] at 3:07PM V5, Regional Director of Operations and V18, Regional Director of Clinical Operations were notified of the Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF742Jun 11, 2024

  Based 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. […]