Arcadia Care Center

In the surveyor’s words

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

• Actual harm, isolatedF770Jan 30, 2025

  Based on interview and record review, the facility failed to provide the laboratory (a room or building equipped for experimental study in science or for testing and analysis) services (laboratory services/laboratory tests included certain blood tests and urinalysis [UA- a medical test that examines a person's urine to detect and diagnose different health conditions], that helped healthcare professionals to detect and treat diseases) for one of three sampled residents (Resident 2) according to the facility's policy and procedures (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, by failing to: Ensure assigned licensed nurses (Licensed Vocational Nurses [LVNs] and/or Registered Nurses [RN] carried out (to do or complete) a physician order dated 1/8/2025 for a UA with… […]

• Actual harm, isolatedF689Jan 3, 2024

  Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of nine sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when CNA 1 turned Resident 1 to one side to change the resident ' s adult brief (disposable underwear) on the bed as indicated in Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/18/2023. 2. […]

• No harm, potential for more than minimal, widespreadF880Jan 19, 2021

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus, a severe respiratory illness caused by virus and spread from person to person) in accordance with the local Public Health guidelines, facility's policy and Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) by failing to: 1. Conduct COVID symptoms and temperature checks at least twice daily for staffs in the Yellow zone (unit for residents who have been exposed to COVID-19) and Red zone (unit for residents who are COVID-19 positive). 2. […]

• No harm, potential for more than minimal, patternF657Jun 30, 2026

  Based on interview and record review, the facility failed to ensure the facility reviewed, updated, and/or revised new interventions for one of three sampled residents (Resident 1) care plan (a document that outlines a person's health needs and the care they require) for falls that occurred on 6/19/2026, 6/20/2026, and 6/26/2026. This deficient practices caused subsequent falls to Resident 2, potentially placing Resident 2 at risk for great bodily injury. During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included malignant neoplasm of brain (cancerous brain tumor) and diabetes mellitus (a disease in which the body's ability to produce or respond to the… […]

• No harm, potential for more than minimal, patternF726Jun 30, 2026

  Based on interview and record review, the facility failed to ensure nursing staff demonstrated and maintained competency to safely provide care and services in accordance with professional standards for one of three sampled residents (Resident 1) when:1. Licensed Vocational Nurse (LVN) 1 failed to follow Resident 1's doctor's order for oxycodone (a potent, semi-synthetic pain medication prescribed to treat moderate to severe pain) on 5/11/26 to 5/13/26 and on 5/23/26. 2. LVN 1 did not have the knowledge of medication parameters (specific rules, clinical limits, and measurable values that guide how a drug is given, adjusted, or stopped). […]