Arcadia Care Center
ARCADIA CARE CENTER in ARCADIA, CA — inspection on September 10, 2025.
Found 2 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 an interview on 9/10/2025, at 4:14 p.m., with the DSD, the DSD stated that Resident 1 was called in to see the doctor and the escort, Escort (ESC 1) stated to the nurse Resident 1's daughter would be coming.
During an interview on 9/10/2025, at 5:56 p.m., with Social Services Assistant (SSA), the SSA stated it was determined by email communication, dated 8/28/2025, that Resident 1 needed an escort to ride with her because Resident 1's daughter would meet them at the appointment.
The SSA stated that most likely they wait for the family to meet them at the appointment before leaving.
The SSA stated if the escort needs to leave, they will call family for an estimated time of arrival (ETA) to the appointment.
The SSA stated for the most part escort remains with the patient.
The SSA stated it is important for the safety of the resident, so the resident is not alone.
During a phone interview, on 9/10/2025, at 6:27 p.m., with ESC 1, ESC 1 stated that Resident 1's daughter was not there.
During a review of the facility's Policy and Procedure (P&P), titled, Transportation and Appointments, revised December 2023, the policy and procedure indicated our facility will assist residents in arranging transportation and escort (as indicated for resident with cognitive impairment, diagnosis of Dementia and/or resident's needing physical assistance with transfers and mobility) to/from appointments including when necessary. A member of nursing staff or social services will accompany the resident when the resident's family is not available.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Center
1601 S Baldwin Ave.
Arcadia, CA 91007
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to ensure therapeutic diets were served as ordered for one of four sampled residents (Resident 1). Resident 1 had a Physician's Order (PO) for no additional salt.
This failure had the potential to result in an increased blood pressure (the force of the blood against the artery walls is too high) due to increased salt levels.During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on 8/18/2025 with diagnoses that included hypertension (a condition when the force of the blood against the artery walls is too high), epilepsy (cell activity in brain is disturbed), and unspecified dementia (cognitive [ability to understand and process thoughts] decline).
During a review of Resident 1's History & Physical Examination -V2 (H&P), dated 8/19/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/25/2025, the MDS indicated Resident 1 was cognitively intact and required supervision and touching assistance with eating. A review of the Order Summary Report, dated 8/31/2025, the Order Summary Report indicated that Resident 1's diet order was CCHO (Controlled Carbohydrate/NAS (no additional sodium/salt), regular texture, and regular liquid.
During a phone interview on 9/9/2025, at 10:40 a.m., with Family (FAM 1), FAM 1 stated the Dietary Supervisor (DS) told FAM 1 that Resident 1 requested additional salt with meals and Resident 1 was provided with salt packets. FAM 1 stated Resident 1 had high blood pressure and should not receive salt.
During a phone interview on 9/10/2025, at 1:01 p.m., with FAM 2, FAM 2 stated Resident 1 has a seizure when Resident 1's blood pressure is high. FAM 2 stated Resident 1 should not be given salt.
During an interview on 9/10/2025, at 3:08 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated to follow physician diet orders.
During an interview, on 9/10/2025, at 4:55 p.m., with the Dietary Supervisor (DS), the DS stated that Resident 1's diet orders were a regular diet, and no added salt.
The DS stated Resident 1 always asks for additional salt.
The DS stated Resident 1 was so mad.
The DS stated Mrs.
Dash (salt free seasoning) was offered as an alternative and Resident 1 refused it.
The DS stated resident 1's preferences were followed.
During a subsequent interview on 9/10/2025, at 5:10 p.m., with the DS, the DS stated that the DS did not have documentation that the DS communicated with FAM 1 or FAM 2 that additional salt packets were provided to resident.
The DS stated the DS did not have documentation that the DS informed the physician that Resident 1 requested additional salt packets.
The DS stated Resident 1's diet order indicated do not give Resident 1 no additional salt.
During a review of the facility's Policy and Procedure (P&P), titled, Diet/Therapeutic Diets, revised October 2017, the policy and procedure indicated diets and therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives.
Facility ID: