Arcadia Care Center: Dignity Violations, Call Light Delays - CA

The facility's own policy requires staff to answer call lights immediately, but no longer than five minutes.

Federal inspectors documented the delays during a July 2024 survey that found widespread dignity violations affecting multiple residents. The inspection revealed staff routinely ignored basic protocols designed to protect resident privacy and ensure timely care.

Resident 279, who has cerebral palsy and osteoarthritis, told inspectors she waited 45 minutes for staff to answer her call light on July 21. Unable to wait any longer without having bowel or bladder incontinence, she walked to the bathroom alone despite needing assistance.

"The facility staff took a long time at night to come and help," Resident 279 told inspectors during a July 22 interview.

Director of Nursing acknowledged the failures during interviews with inspectors. She said residents "could feel frustrated because the residents were not able to care for themselves" and would "feel worthless if they have to wait too long for their call lights to be answered by staff."

The inspection uncovered additional dignity violations when staff entered rooms and bathrooms without knocking. On July 23, Licensed Vocational Nurses 2 and 7 entered a shared room twice without knocking while a female visitor was present. The same nurses then opened a bathroom door without knocking while Resident 75 was inside using the restroom.

Resident 75 told inspectors he "got startled" when the nurse opened the bathroom door without knocking first.

The facility's policy explicitly requires staff to "knock and request permission before entering residents' rooms" to maintain dignity and show respect.

Staff also violated feeding protocols that the facility established to preserve resident dignity. During a July 22 lunch observation, inspectors watched Speech Therapist 1 feed Resident 15 while standing rather than sitting at eye level with the resident.

The Director of Nursing told inspectors that "standing while feeding a resident would degrade the resident."

Two days later, Activity Assistant 1 was observed feeding Resident 13 while standing. The assistant acknowledged to inspectors that she "needed to sit down next to Resident 13 when feeding."

The facility's own policy states "Staff must be seating when feeding residents."

Beyond dignity violations, inspectors found critical failures in medical decision-making for residents without family representatives. Resident 19, who had lung cancer and severely impaired cognitive skills, lacked a responsible party to make medical decisions. Instead of convening the facility's Bioethics Committee as required by policy, two nurses signed the resident's advance directive documents and POLST forms.

RN 1 told inspectors she and RN 3 "were instructed to sign Resident 19's documents" but didn't know if the facility had a Bioethics Committee for unrepresented residents.

The Administrator later confirmed that "nurses alone were not capable to make decisions for the unrepresented resident" and that such cases should be referred to the facility's Bioethics Committee.

The facility also failed to notify physicians of critical medical changes. When Resident 14's blood sugar spiked to 420 mg/dL on July 1 — well above the 400 mg/dL threshold requiring physician notification — Licensed Vocational Nurse 3 admitted the doctor was never called.

"Since it was not documented then it was not done," LVN 3 told inspectors. The facility's medication orders specifically required staff to "call the Medical Doctor for blood sugar level above 400 mg/dL."

The Director of Nursing said physician notification was "important so that the MD can determine if Resident 14's insulin needed to be adjusted and determine the type of care needed."

Additional violations included failing to provide written Medicare Advance Beneficiary Notices to responsible parties of two residents whose skilled care coverage was ending. The Business Office Manager acknowledged she did not provide written copies of the notices despite facility policy requiring written notification.

The facility also compromised resident privacy by allowing Resident 75 to use a shared bathroom belonging to other residents. The Infection Preventionist told inspectors this created privacy problems, particularly "if the resident using the restroom was a male and the resident in the room sharing the restroom were females."

Inspectors found additional safety failures, including beds not positioned at the lowest setting for high fall-risk residents and missing floor mats for residents with fall histories.

The inspection documented violations affecting residents with conditions ranging from Parkinson's disease and COPD to diabetes and spinal stenosis. Many residents required substantial assistance with daily activities like toileting, bathing, and dressing.

Resident 120, who was admitted in June with spinal stenosis and muscle weakness, told inspectors he "felt frustrated when he waited a long time to get assistance from the facility staff." His care plan specifically indicated staff should "offer and assist" with bathroom use as needed.

The facility's own policies acknowledge that "demeaning practices and standards of care that compromise dignity are prohibited" and require staff to "promote dignity and assist residents" by "promptly responding to a resident's request for toileting assistance."

Yet the inspection found systematic failures to follow these basic protocols, leaving residents waiting hours for help or forced to manage without assistance to avoid incontinence.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Arcadia Care Center from 2024-07-25 including all violations, facility responses, and corrective action plans.

Additional Resources

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