Arcadia Care on the Hill

In the surveyor’s words

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

• Immediate jeopardy, widespreadF658Sep 17, 2025

  Based on interview and record review, the facility failed to ensure competency of the Professional Nursing staff for 1 of 6 (R5) reviewed for Professional Standards in the sample of 50. This failure has the potential to affect all 128 Residents residing in the facility.The immediate jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. V6 failed to follow physician's order of administering Baqsimi (Glucagon) for low blood sugar, and instead disassembled prefilled Epinephrine and Narcan cartridges, combining pieces of both medication cartridges, and administered Epinephrine injection nasally. […]

• Immediate jeopardy, isolatedF760Sep 17, 2025

  Based on interview, observation, and record review, the facility failed to provide a resident in a crisis condition the correct medication for 1 of 6 residents (R5) reviewed for medication errors in the sample of 50. This failure resulted in the R5 not receiving his Glucagon when needed resulting in his blood sugar dropping to a critical low and being transferred to the hospital and subsequently admitted to the Intensive Care Unit (ICU).The Immediate Jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. […]

• Immediate jeopardy, isolatedF689Aug 24, 2023

  Based on interview, observation and record review, the facility failed to monitor and supervise a resident with severe cognitive impairment for 1 of 1 resident (R4) reviewed for supervision in the sample of 5. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/31/23 when the facility failed to identify that R4 was missing, last seen at around 11:00AM and discovered entrapped on the elevator at 10:30 PM. This Past Noncompliance occurred from 7/31/23 to 8/1/23. On 8/22/23 at 3:03 PM, the V1, Administrator, V2, Director of Nursing (DON) and V22, [NAME] President of Operations, were notified of the Immediate Jeopardy. […]

• Actual harm, isolatedF686Jul 27, 2026

  Based on observation, interview, and record review, the facility failed to identify and treat a stage three pressure ulcer for one (R28) of three residents reviewed for wound care in a sample list of 121Findings include:R28's Face Sheet documents R28 has the diagnoses of Metabolic Encephalopathy, Major Depressive Disorder, Acute Kidney Failure, Severe Morbid Obesity, and Diabetes Mellitus Type two.R28's Braden Scale dated 4/30/26 documents a risk score of 13, indicating R28 is at moderate risk of skin breakdown.R28's Minimum Data Set (MDS) dated [DATE] documents R28 is alert and oriented and is dependent on staff for Activities of Daily Living, including turning and positioning. […]

• Actual harm, isolatedF689Jul 27, 2026

  Based on observation, interview and record review, the facility failed to safely transfer a resident, investigate a fall to determine root cause, and failed to initiate progressive interventions to prevent further falls for 3 of 3 residents (R2, R5 and R6) reviewed for falls in the sample list of 121. This failure resulted in R2 suffering significant pain during multiple transfers. Findings include: 1. On [DATE] at 1:44 PM, R2 was observed alert and seated upright in a wheelchair with a mechanical lift sling positioned underneath the resident. […]