Arcadia Care Center
ARCADIA CARE CENTER in ARCADIA, CA — inspection on July 25, 2024.
Found 13 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 75's MDS, dated 6/25/24, the MDS indicated Resident 75 had intact cognition.
During a review of Resident 86's AR, the AR indicated, Resident 86 was admitted to the facility on [DATE] with diagnoses including other specified diseases of liver, kidney failure and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability).
During a review of Resident 86's MDS, dated 5/28/2024, the MDS indicated Resident 86 had severely impaired cognitive skills.
During a review of Resident 86's H&P, dated 6/6/2024, the H&P indicated, Resident 86 did not have the capacity to understand and make decisions.
During an observation on 7/23/2024 at 8:59 a.m. Resident 86 was in the room in bed and had a female visitor (unnamed). Resident 13 (Resident 86's roommate) was also in the room. Resident 13 was sitting up in a wheelchair at Resident 13's bedside. LVN 2 and LVN 7 were observed entering and exiting Resident 86 and Resident 13's room twice without knocking. LVN 2 then opened the restroom without knocking and Resident 75 was inside using the restroom. LVN 2 and LVN 7 stated, staff needed to knock the door to maintain the resident's dignity.
During an interview on 7/24/2024 at 12:30 p.m. with the Director of Nursing, the DON stated, the facility's policy was for staff to knock before entering, introduce themselves and state their purpose.
The DON stated, it was important for staff to knock the door, to show respect to the residents, to maintain dignity and for those residents with impaired vision to identify who the staff was.
During an interview on 7/24/2024 at 1:06 p.m. with Resident 75, Resident 75 stated, Resident 75 got startled when LVN 2 opened the door to the restroom where Resident 75 was using without LVN 2 knocking first.
During a review of the facility's P&P titled, Resident Rights, revised December 2019, the P&P indicated, employees should treat all residents with kindness, respect, and dignity.
The P&P indicated, a list of resident's rights including right to a dignified existence and be treated with respect, kindness, and dignity.
During a review of the facility's P&P titled, Dignity, revised February 2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
The P&P indicated, one of the many policy interpretation and implementation included residents are treated with dignity and respect at all times.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a review of Resident 19's History and Physical (H&P), dated 6/28/2024, the H&P indicated Resident 19 did not have the mental capacity to understand and make medical decisions.
During a concurrent interview and record review on 7/24/2024 at 11:54 AM with RN 1, Resident 19's POLST, dated 6/24/2024, and Resident 19's Advanced Directive Acknowledgement, dated 6/24/2024, were reviewed. RN 1 and RN 3 signed the documents indicating RN 1 and RN 3 were Resident 19's representative and legally recognized decisionmaker. RN 1 stated RN 1 and RN 3 were instructed to sign Resident 19's documents. RN 1 stated Resident 19 did not have a responsible party to represent Resident 19. RN 1 stated RN 1 did not know if the facility had a Bioethics Committee to make decisions for residents (in general) who were not capable to make decisions and did not have representatives.
During an interview on 7/24/2024 at 12:00 PM with the facility's Administrator (ADM), the ADM stated if a resident was admitted to the facility and did not have a representative, but was self-responsible, the resident could sign their own admission documents (including POLST and AD Acknowledgment).
The ADM stated if the resident did not have a representative and did not have the capacity to make their own decisions, the facility would refer to the facility's Bioethics Committee.
The ADM stated the Bioethics Committee would consist of different staff members representing different areas affecting the resident care.
The ADM stated nurses alone ( RN1 and RN 3) were not capable to make decisions for the unrepresented resident (in general).
During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, revised December 2016, the P&P indicated, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.
During a review of the facility's policy and P&P titled, Bioethics, dated November 2021, the P&P indicated, It is the policy of this facility to uphold the rights of residents to participate in medical decisions.
Sometimes situations arise wherein the decisions may be too complex for the surrogate decision-maker, or there is no surrogate.
The P&P indicated, The Bioethics Committee is comprised of at least one physician, facility administrator, and a representative from nursing, social service, activities, dietary, rehabilitation, business office, and other departments as indicated.
Furthermore, any facility staff member who has knowledge of the resident may be invited to attend.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a review of Resident 14's admission Record, the AR indicated Resident 14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (long term condition in which a high level of sugar is present in the bloodstream), liver cirrhosis (a type of liver disease where healthy cells are replaced by scar tissue) and hyperlipidemia (excess of fat or lipids in the blood).
During a review of Resident 14's History and Physical (H&P) dated 2/27/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions.
During a review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/23/2024, the MDS indicated Resident 14 was dependent (helper does all of the effort to complete the activity) on staff for toilet use and personal hygiene.
During a concurrent telephone interview and record review on 7/25/2024 at 1:08 pm with Licensed Vocational Nurse 3 (LVN 3), Resident 14's MAR dated with active orders as of 7/25/2024 was reviewed.
The MAR indicated Resident 14's blood sugar level was 420 mg/dL on 7/1/2024 at 4:30 pm.
The MAR indicated for licensed staff to call the Medical Doctor (MD) for blood sugar level above 400 mg/dL. LVN 3 stated LVN 3 could not remember if the MD was notified but since it was not documented then it was not done. LVN 3 stated Resident 14's MD should have been notified of the elevated blood sugar according to the physician's order.
During a concurrent interview and record review on 7/25/204 at 4:36 PM with Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/2017 was reviewed.
The P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): i. specific instruction to notify the Physician of changes in the resident's condition.
The DON stated if it wasn't documented then it was not done, and the doctor should have been notified per physician's order.
The DON stated it was important for the MD to be notified so that the MD can determine if Resident 14's insulin needed to be adjusted and determine the type of care needed for Resident 14.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a telephone interview on 7/25/2024 at 10:24 AM, RP 179 stated she could not recall being informed about or receiving a written copy of Resident 179's ABN 2.
During a concurrent interview and record review on 7/25/2024 at 10:48 AM with BOM, Resident 179's ABN 2 was reviewed.
The BOM stated she did not provide a written copy of ABN 2 to RP 179.
During an interview on 7/25/2024 at 3:15 PM, Business Office Assistant (BOA) stated not providing ABN in writing per facility policy would lead to missed information relayed to the resident or responsible party (in general).
During a review of the facility's policy and procedure (P&P 6), titled Medicare Advance Beneficiary Notice, dated 4/2021, P&P 6 indicated the following:
- If the Admissions/Benefits Coordinator believes (upon admission or during the resident's stay) that
- The facility must issue the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055)
Medicare Part A of the Fee for Service Medicare Program would not pay for an otherwise covered skilled service(s), the resident or representative must be notified in writing why the service(s) might not be covered and of the resident's potential liability for payment of the non-covered service(s).
to the resident prior to providing care that Medicare usually covers but might not pay for because the care is considered not medically reasonable and necessary, or custodial.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a review of Resident 75's admission Record (AR), the AR indicated, Resident 75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease (ESRD, kidneys lose the ability to remove waste and balance fluids) and essential (primary) hypertension (high blood pressure).
During a review of Resident 75's History and Physical Examination (H&P), dated 10/5/2023, the H&P indicated Resident 75 had the capacity to understand and make decisions.
During a review of Resident 75's Minimum Data Sheet (MDS, an assessment and screening tool) dated 6/25/2024, the MDS indicated Resident 75 had intact cognition (ability to think and process information).
During a concurrent observation and interview on 7/23/2024 at 8:59 a.m. with LVN 2, LVN 2 opened the door of the [NAME] & [NAME] restroom and saw Resident 75 using the restroom. LVN 2 stated, Resident 75 was from another room.
During an interview on 7/24/2024 at 12:44 p.m. with the Infection Preventionist (IP), the IP stated, residents from another room should not use the shared restroom (Jack and [NAME] restroom) for privacy.
The IP stated, it would be a problem if the resident using the restroom was a male and the resident in the room sharing the restroom were females.
During an interview on 7/24/2024 at 1:06 p.m. with Resident 75, Resident 75 stated, he used the other residents' restroom on 7/23/2024 because Resident 75's [NAME] and [NAME] restroom was occupied, and the other restroom was not in use. Resident 75 stated, he had an appointment yesterday (7/23/2024) and had to urgently use a restroom. Resident 75 stated, a staff (unnamed) told Resident 75 to use the [NAME] and [NAME] restroom across the hallway.
During an interview on 7/25/2024 at 3:11 p.m. with the Director of Nursing (DON), the DON stated, if residents are not from that area (adjoining rooms sharing the [NAME] and [NAME] restroom), staff should not allow other residents to use the restroom for reasons of privacy and dignity.
The DON stated, even family members were encouraged not to use the resident's restroom.
During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life - Homelike Environment, revised May 2017, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a review of Resident 55's MDS dated 4/8/2024, the MDS indicated Resident 55 had moderately impaired cognitive skills (ability to make daily decisions).
The MDS indicated Resident 55 required partial/moderate (helper does less than half the effort) from staff for toileting and bathing.
During a review of Resident 55's care plan titled Fall Risk, dated 7/20/2024, the care plan indicated Resident 55 had a history of falling.
The care plan indicated Resident 55 was at high risk of falling.
The care plan indicated facility staff needed to place Resident 55's bed in the lowest position.
The care plan indicated to place floor mats on both sides of Resident 55's bed.
During a review of Resident 55's Assessment Outcome, dated 7/20/2024, the Assessment Outcome indicated Resident 55 was at a high risk of falling.
During a concurrent observation and interview on 7/24/2024 at 12:36 PM, with LVN 2 in Resident 55's room, Resident 55's bed was in a raised position.
There were no floor mats on either side of Resident 55's bed. LVN 2 lowered the bed to its lowest position.
During an interview on 7/25/2024 at 10:00 AM with the Director of Nursing (DON), the DON stated the purpose of Resident 55's floor mats were to minimize injuries if Resident 55 fell.
During a review of the facility's P&P titled, Falls - Clinical Protocol, revised March 2018, the P&P indicated, Based on the preceding assessment. the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a review of Resident 49's admission Record (AR), the AR indicated Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure (a condition that develops when one's heart doesn't pump enough blood for the body's needs), end stage renal disease (a condition in which a person's kidney's stop functioning on a permanent basis) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working).
During a review of Resident 49's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/30/2024, the MDS indicated Resident 49 had severe impairment with cognitive skills (ability to make decisions, reason).
The MDS indicated Resident 49 was dependent (helper does all of the effort) on staff for toileting and eating.
During a review of Resident 49's Order Summary Report, (OSR) dated with active orders as of 7/24/2024, the OSR indicated fluid restriction 1000 milliliters (ml-unit of volume) per 24 hours.
Dietary total limit, 600 ml: Breakfast, 240 ml Lunch - 120 ml Dinner - 240 ml Nursing total limit 400 ml: Day shift 180 ml Evening shift - 180 ml Night shift - 40 ml every shift.
During a concurrent interview and record review on 7/24/2024 at 11:44 AM with Licensed Vocational Nurse 4 (LVN 4), Resident 49's Intake and Output Form (I&O) was reviewed.
The I&O did not indicate any record of Resident 49's intake or output on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024. LVN 4 stated Resident 49 had an active order for fluid restriction and all intakes and outputs should be recorded on the I&O form by the nursing staff. LVN 4 stated Resident 49 had a fluid restriction because Resident 49 required dialysis and if the fluid restriction was not followed it would lead to fluid overload for Resident 49.
During a concurrent interview and record review on 7/25/2024 at 4:36 AM with the Director of Nursing (DON), Resident 49's I&O was reviewed.
The DON stated there was no documentation for input or output on 7/2/2024, 7/4/2024, 7/5/2024, 7/9/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/23/2024 and there had been no documentation from the nightshift for any dates from 7/1/2024 to 7/23/2024.
The DON stated the facility could not prove the fluid restriction was being followed because of the missing documentation and if the restriction was not followed it would result to shortness of breath, edema (water retention) and overall decline in health for Resident 49.
During a review of the facility's Policy and Procedure (P&P) titled, Intake and Output dated 6/2019, the P&P indicated intake and output shall be documented when indicated by resident's condition and/or treatment.
The P&P further indicated nursing staff shall be responsible for documenting the intake and output each shift and record in the medical record.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
Line: An Alternate for a Food Item Resident Does Not Like That is Recorded on the Tray Card, P&P 5
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During an observation of DW 1's dishwashing and sanitizing practices on 7/25/2024 at 3:25 PM with the Dietary Services Supervisor (DSS), DW 1 washed and rinsed the dirty pans and trays in the sink, then touched the metal trays that were sanitized in the dishwasher.
During an interview on 7/25/2024 at 3:26 PM, DSS stated DW 1 was not supposed to touch or move the sanitized metal trays while washing the dirty pans and trays. DSS stated another staff member, Dietary Aide 2 (DA 2), was assigned to put away the sanitized metal pans and trays to prevent cross-contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) of items that come in contact with food.
During a review of the facility's Policy and Procedure (P&P 3), titled, Dish Washing, dated 2018, P&P 3 indicated all dishes must be properly sanitized through the dishwasher.
In addition, during a review of the facility's Policy and Procedure (P&P 1), titled Standard Precautions, Enhanced Barrier Precautions and Transmission-Based Precautions, dated 6/25/2024, P&P 1 indicated the facility must provide guidelines for infection control practices to reduce the potential for transmission of pathogens. P&P 1 indicated when handling dishes, all tableware must be treated as contaminated and must be sanitized according to facility protocol.
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
admission to the facility. P&P 2 indicated resident has the right to refuse to enter into the arbitration
During a review of the facility's P&P titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 6/25/24, the P&P indicated, the purpose of the P&P was to provide guidelines for infection control practices to reduce the potential for transmission of pathogens (any organism that causes disease).
555729 07/25/2024
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a review of Resident 279's Admission Record (AR) the AR indicated Resident 279 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (type of joint disease that results from breakdown of joint cartilage [connective tissue] and underlying bone) of the left knee, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), and hyperlipidemia ( high level of fat particles [lipids] in the blood).
During a review of Resident 279's care plan titled Bladder and Bowel Retraining, dated 7/20/2024, the care plan indicated facility staff should offer and assist Resident 279 use of the bathroom as needed.
During a review of Resident 279's care plan titled Fall Risk, dated 7/20/2024, the care plan indicated Resident 279 had a history of falling.
The care plan indicated Resident 279 required 1 person assistance from staff for assistance to transfer from the bed.
During a review of Resident 279's History and Physical (H&P), dated 7/23/2024, the H&P indicated Resident 279 had the capacity to make medical decisions.
During an interview on 7/22/2024 at 10:21 AM with Resident 279, Resident 279 stated on 7/21/2024, Resident 279 waited 45 minutes for staff to answer Resident 279's call light during the nighttime shift. Resident 279 stated Resident 279 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. Resident 279 stated the facility staff took a long time at night to come and help Resident 279. Resident 279 stated Resident 279 had to walk by herself to the bathroom.
During an observation on 7/24/2024 at 8:33 AM, Resident 279 was walking alone in her room.
There were no staff in Resident 279's room.
555729
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555729 B.
Wing 07/25/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
During a review of Resident 120's AR, the AR indicated Resident 120 was admitted to the facility 6/28/2024 with diagnoses including spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), muscle weakness, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).
During a review of Resident 120's care plan titled Bladder and Bowel Retraining, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 use of the bathroom as needed.
During a review of Resident 120's care plan titled ADL and Functional Mobility, dated 6/28/2024, the care plan indicated facility staff should offer and assist Resident 120 with Activities of Daily Living (ADLs, activities related to personal care) as needed.
During a review of Resident 120's H&P dated 6/29/2024, the H&P indicated, Resident 120 had the capacity to make medical decisions.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555729
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555729 B.
Wing 07/25/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Center 1601 S Baldwin Ave.
Arcadia, CA 91007
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.