Arcadia Care Jacksonville

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 14, 2023

  Based on interview, observation and record review, the facility failed to provide adequate supervision and provide a secure environment to prevent elopement for 1 of 16 residents (R2) reviewed for elopement in the sample of 18. This failure resulted in R2 eloping without staff knowledge and has the potential to affect all 16 residents identified as being at risk for elopement (R1, R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 and R18). This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 04/09/23 when R2 left the facility at 4:21PM without staff knowledge and was found by the local police department at 7:10 PM. V1 was notified of the Immediate Jeopardy on 04/12/23 at 13:30pm. […]

• Actual harm, isolatedF684Jul 8, 2026

  Based on interview and record review, the facility failed to follow the physician's order for a STAT x-ray and failed to notify the physician of inability to follow the physician's STAT order for one or three residents (R5) reviewed for post fall assessment and treatment in the sample list of 14. This failure resulted in a delay in diagnostic evaluation and treatment of a fracture causing undo pain. Findings Include:R5's face sheet documents an admission date of 07/25/2018 with diagnoses including: Schizophrenia Unspecified, Other Lack of Coordination, Vitamin D Deficiency and Cognitive Communication Deficit.R5's nursing progress note dated 3/20/2026 at 6:09PM written by V10 (Licensed Practical Nurse/LPN) documents that R5 sustained a fall on 3/20/2026 at 3:30pm and complained of pain at a… […]

• Actual harm, isolatedF684Nov 25, 2024

  Based on interview, observation, and record review, the facility failed to coordinate services for a neurology consult for abnormal movements, falls and a gagging incident for 1 of 16 residents (R30) reviewed for quality of care in the sample of 35. This failure resulted in R30 having increased involuntary movements that resulted in worsening involuntary movements. Findings include: R30's Admission record, print date of 11/21/24, documents that R30 was admitted on [DATE] and has diagnoses of Psychosis, Schizoaffective Disorder, Drug Induce Subacute Dyskinesia, and Schizophrenia. R30's Minimum Data Set, dated dated [DATE], documents that R30 is severely cognitively impaired, requires setup or clean up assistance for eating, supervision or touching assistance for sitting and walking. […]

• Actual harm, isolatedF550Aug 21, 2024

  Based on interview, observation and record review, the facility failed to promote residents' dignity by addressing residents' needs timely for 4 of 5 residents (R2, R3, R4, R5) reviewed for dignity in the sample of 5. This failure resulted in R2 feeling humiliated after having to urinate in her water pitcher due to staff not assisting her. Findings include: 1. On 8/16/24 at 8:55 AM, R2 was in her bed with a large cow bell and air horn at bedside. R2 stated the call lights are not working and haven't been for a while. R2 stated they are telling her that the part has been ordered and when it comes in, it will be installed but they haven't given her a time frame for when that will occur. […]

• Actual harm, isolatedF550Nov 8, 2023

  Based on observation, interview and record review the facility failed to ensure a resident was treated with dignity by ensuring privacy when urinating and allowing residents to eat at same time as other residents for 4 of 4 residents (R10, R16, R63, R70) observed for dignity in the sample of 46. This failure resulted in R16 feeling frustrated and sitting hungry awaiting his food for an hour after meal service. Findings include: 1. On 11/5/2023 at 12:46 PM hall trays were placed on 100- hall. From 12:46 PM to 12:52 PM, hall trays were passed to the residents on the hall. At 12:47 PM R16 was sitting in his wheelchair in his room. R64's, R16's roommate's tray was placed on R64's over bed table next to R16. On 11/5/2023 at 1:00 PM was R16 sitting in wheelchair in room with no food tray. […]