ARCADIA, CA - Federal inspectors found serious deficiencies in resident care at Arcadia Care Center following a July 2024 inspection, documenting failures that put vulnerable residents at risk including delayed response times, inadequate fall prevention measures, and infection control breakdowns.
Delayed Emergency Response Endangers Residents
Staff Response Time Failures Compromise Safety
The most alarming finding involved a resident with cerebral palsy and a history of falls who waited 45 minutes for staff to respond to a call light during the night shift. The resident, identified as Resident 279, told inspectors they "had to go to the bathroom without assistance from staff because Resident 279 could not wait for staff any longer or Resident 279 would have bowel or bladder incontinence."
This delay occurred despite the resident's care plan explicitly requiring one-person assistance for transfers and bathroom use. When staff finally arrived, they found the resident walking alone in their room without supervision, directly violating established safety protocols.
The failure to respond promptly to call lights represents a critical breakdown in basic nursing home care. Residents with mobility limitations and fall risks require immediate assistance to prevent injuries that could result in fractures, head trauma, or other serious complications. For residents with cerebral palsy, unassisted movement can be particularly dangerous due to balance and coordination challenges.
According to nursing home standards, call lights should be answered within five minutes during the day and ten minutes at night. The 45-minute delay documented at Arcadia Care Center represents a ninefold violation of acceptable response times, leaving vulnerable residents in potentially life-threatening situations.
Fall Prevention Measures Ignored Despite High-Risk Status
Critical Safety Equipment Missing for At-Risk Resident
Inspectors discovered that Resident 55, who had been assessed as high risk for falls with a history of falling, was not receiving proper fall prevention measures. The resident's care plan specifically required their bed to be kept in the lowest position with floor mats placed on both sides of the bed to minimize injury risk.
During the inspection, staff found the resident's bed in a raised position with no floor mats present on either side. Only after the inspector's prompting did the Licensed Vocational Nurse lower the bed to its proper position.
Floor mats serve as a crucial safety intervention for fall-prone residents. When placed beside beds, these mats can reduce the risk of serious injury by up to 50% if a resident falls while attempting to get out of bed. The mats provide cushioning that can prevent hip fractures, head injuries, and other trauma that commonly occurs when elderly residents fall onto hard flooring.
The Director of Nursing acknowledged that the floor mats were specifically intended to "minimize injuries if Resident 55 fell," highlighting the staff's awareness of the safety equipment's importance despite their failure to implement it consistently.
For nursing home residents, falls represent one of the leading causes of serious injury and death. Falls result in over 32,000 deaths annually among older adults, with nursing home residents facing particularly high risks due to medications, cognitive impairment, and mobility limitations. Proper fall prevention protocols are not optional safety measures but essential interventions that can mean the difference between life and death.
Dialysis Patient Care Compromised by Documentation Failures
Critical Fluid Monitoring Lapses Threaten Life-Sustaining Treatment
The facility failed to properly monitor fluid restrictions for Resident 49, a patient requiring dialysis who had strict orders limiting fluid intake to 1,000 milliliters per 24-hour period. Documentation gaps were found on eight separate days throughout July 2024, with no recorded intake or output measurements.
The resident's physician had ordered specific fluid distribution: 600ml through dietary sources and 400ml through nursing care, carefully divided across all shifts. However, intake and output forms showed complete gaps in documentation on July 2, 4, 5, 9, 14, 15, 21, and 23, with no nightshift documentation recorded for the entire monitoring period.
The Licensed Vocational Nurse confirmed that proper fluid restriction monitoring was essential because "if the fluid restriction was not followed it would lead to fluid overload for Resident 49." The Director of Nursing admitted the facility "could not prove the fluid restriction was being followed because of the missing documentation."
For dialysis patients, strict fluid management is literally a matter of life and death. Excess fluid accumulation can cause pulmonary edema, where fluid builds up in the lungs, making breathing difficult or impossible. It can also lead to dangerous swelling throughout the body and put excessive strain on the heart, potentially causing heart failure.
Dialysis removes excess fluid from the body, but patients must carefully limit fluid intake between treatments to prevent dangerous accumulation. A single day of excess fluid intake can result in emergency hospitalization or even death. The facility's inability to document whether this critical restriction was being followed represents a fundamental failure in life-sustaining care.
Infection Control Breakdowns Risk Disease Transmission
Personal Protective Equipment Protocols Violated
Two separate incidents demonstrated serious gaps in infection control practices that could facilitate the spread of dangerous pathogens throughout the facility. In the first incident, a Certified Nursing Assistant entered the room of a resident with C. difficile infection without wearing required protective equipment.
The resident was on contact isolation precautions, with clear signage posted and an isolation cart containing protective equipment placed outside the room. Despite these obvious warnings, the CNA entered to deliver a meal tray without donning the required gown and gloves, stating they "did not wear the required PPE as posted because CNA 1 was only delivering a meal tray and not providing resident care."
C. difficile is a highly contagious bacteria that causes severe intestinal infections and can be fatal, particularly for elderly or immunocompromised patients. The bacteria can survive on surfaces for months and spreads easily through contact with contaminated hands, clothing, or equipment. Contact isolation protocols exist specifically to prevent this transmission.
In a second violation, a Licensed Vocational Nurse used toilet paper from a shared bathroom to administer eye drops to a resident. The nurse later acknowledged the practice was inappropriate, noting "the toilet paper could be contaminated." The Infection Preventionist confirmed that using toilet paper from shared facilities for medical procedures violated infection control standards because "the toilet paper in the restroom could have been touched by multiple people and could have been contaminated."
Additional Issues Identified
Inspectors documented several other concerning violations:
Dietary Violations: Kitchen staff served fish to a resident whose dietary preferences clearly indicated "No Fish," requiring immediate meal replacement during the inspection.
Food Safety: A dishwasher was observed touching sanitized equipment while handling dirty items, creating cross-contamination risks that could lead to foodborne illness.
Legal Documentation: The facility failed to properly explain arbitration agreements to family members, with one responsible party stating they signed documents without understanding their purpose or legal implications.
These multiple violations paint a picture of systemic care deficiencies at Arcadia Care Center, where basic safety protocols and resident care standards were not consistently followed across multiple departments and shifts.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arcadia Health Care Center from 2024-07-25 including all violations, facility responses, and corrective action plans.
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