Onyx Care of Arcadia

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 26, 2023

  Based on record review and interview, the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #1, who was cognitively impaired, on 06/20/2023 when Resident #2, who was cognitively impaired, was found on top of Resident #1 in her bed in her room. When discovered, Resident #1 stated, Help me. Help me. Resident #1 was nude from the waist down and Resident #2 was nude. Based on interview with Resident #1's responsible party (RP), the RP reported that Resident #1 wouldn't have wanted the sexual activity to happen and the sexual activity would have never been okay with her. […]

• Actual harm, isolatedF600Feb 1, 2023

  Based on record review and interview, the facility failed to protect the residents' right to be free from physical abuse and psychosocial harm by another resident for 1 (#2) of 5(#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #2, who was cognitively impaired, on 08/23/2022 when Resident #1 physically abused Resident #2 in the dining room by hitting Resident #2 with a closed hand in the mouth. Resident #2's removable dental bridge was knocked out of his mouth and he sustained a scratch on his upper lip. Resident #2 was also noted to be extremely upset and angry. […]

• No harm, potential for more than minimal, patternF755Aug 26, 2026

  Based on record reviews and interviews, the facility failed to ensure 1 (#1) out of 3 (#1, #2, #3) sampled resident's medications were not diverted. The facility failed to ensure deceased resident's narcotic controlled medications were destroyed in a timely manner to prevent the potential for diversion. Findings: Review of the facility's Narcotics Policy dated [DATE] and reviewed [DATE] revealed in part:8. If a resident is discharged to the hospital, expires, or medication is discontinued, the medications should stay in the medication cart for counting until such time as they can be destroyed.9. Medication destruction should occur by the DON (director of nurses) and a second nurse. […]

• No harm, potential for more than minimal, patternF578Sep 17, 2025

  Based on record reviews and interview, the facility failed to inform and provide written information to formulate an advance directive for 5 (#2, #8, #23, #71, #116) out of 5 residents reviewed for advance directives. Findings:Review of Resident #2's medical records revealed an admit date of 02/17/2025. Further review of Resident #2's Resident Rights/Advanced Directive form dated 02/17/2025 failed to provide written information to formulate an advance directive. Review of Resident #8's medical records revealed an admit date of 04/08/2025. Further review of Resident #8's undated Resident Rights/Advanced Directive form signed by representative failed to provide written information to formulate an advance directive. […]

• No harm, potential for more than minimal, patternF757Sep 17, 2025

  Based on record review, observation and interviews the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#8) of 2 (#8, #80) residents reviewed for infections. The facility failed to ensure Resident #8's Tobramycin ophthalmic medication was stopped after indication for use was resolved. Findings:Review of Resident #8's medical record revealed an admission date of 04/08/2025 with diagnoses that included, in part, hordeolum externum left eyelid, type 2 diabetes mellitus without complications, and end stage renal disease. Review of Resident #8's physician orders revealed a 05/13/2025 order for Tobramycin opthalmic ointment 0.3% - Instill 0.5 drop in left eye every 8 hours for hordeolum externum left upper eyelid. […]