A list of the most recent deficiencies for Arcadia Retirement Residence. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-03 | 2023-12-15 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-11-03 | 2023-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-03 | 2023-12-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-03 | 2023-12-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-03 | 2023-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-03 | 2023-12-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-03 | 2023-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-03 | 2023-12-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-03 | 2023-12-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-03 | 2023-12-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-03 | 2023-12-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-03 | 2023-12-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-03 | 2023-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-07 | 2023-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2023-11-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-07 | 2023-11-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-22 | 2023-02-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-22 | 2023-02-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-22 | 2023-02-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-22 | 2023-02-11 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-22 | 2023-02-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-12-22 | 2023-02-11 | N |
| Post nurse staffing information every day. | Health | 2022-12-22 | 2023-02-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-22 | 2023-02-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-22 | 2023-02-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-02-11 | N |
| Keep all essential equipment working safely. | Health | 2022-12-22 | 2023-02-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-22 | 2023-02-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-22 | 2023-02-11 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-02-16 | 2022-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-16 | 2022-04-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-02-16 | 2022-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-16 | 2022-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-16 | 2022-04-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-18 | 2022-03-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-18 | 2022-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-03-11 | N |
