Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leslie Lakes Retirement Center during CMS and state inspections, most recent first.
Failure to document bleeding monitoring for a resident receiving Eliquis. The resident had atrial fibrillation, dementia, schizophrenia, and other chronic conditions, and the care plan identified risk for bruising and bleeding related to anticoagulant therapy. Although the MAR showed Eliquis 2.5 mg BID, there was no documented evidence of monitoring for signs and symptoms of bleeding, which the DON confirmed.
The facility failed to follow infection control practices during medication pass, wound care, and whirlpool use. An LPN did not perform hand hygiene before, between, or after medication administration and picked up dropped medication with an ungloved hand before giving it to a resident. A CNA exited a resident's room without doffing PPE during wound care for a resident on EBP, and a whirlpool tub was observed with a brown substance and hair inside.
A resident’s right to a clean and comfortable environment was not maintained when surveyors observed persistent spills on the bedside table and tube feeding pole, along with visible black substance and grime on the room’s air conditioning unit. Over multiple days, these unsanitary conditions remained, and both housekeeping and maintenance staff later confirmed the presence of the spills, splatters, and grime, as well as the need to change the air filter.
Respiratory care was not provided as ordered for two residents. One resident with pneumonia, dementia, and PRN bronchodilator orders had a nebulizer mask left uncovered and tubing that was not changed weekly, and an LPN confirmed the mask should have been stored in a bag and the tubing changed weekly. Another resident with respiratory failure had O2 via NC with tubing that remained dated beyond the weekly change schedule, and an LPN confirmed the tubing had not been changed as ordered.
A pharmacist failed to identify that a resident receiving Eliquis had no documented monitoring for signs and symptoms of bleeding, despite the care plan identifying bleeding risk and the resident's anticoagulant therapy. The resident had atrial fibrillation, dementia, schizophrenia, and other diagnoses, and the DON confirmed the issue was not addressed in the monthly MRR.
A facility failed to complete a timely MDS admission assessment for a resident. The assessment was due by a specific date but remained incomplete and unsubmitted to CMS as of a later date. This was confirmed by the MDS Coordinator and the DON during interviews.
Failure to Document Bleeding Monitoring for Resident on Eliquis
Penalty
Summary
The facility failed to ensure Resident #11’s medication regimen was free from unnecessary drugs by not documenting monitoring for signs and symptoms of bleeding while the resident was receiving Eliquis for atrial fibrillation. Resident #11 was admitted on 10/21/2025 and had diagnoses including atrial fibrillation, hypothyroidism, hyperlipidemia, schizophrenia, dementia, and depressive disorder. The quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment for daily decision making. The care plan identified the resident as at risk for bruising and bleeding related to anticoagulant therapy and included observing for signs and symptoms of bleeding. Physician orders included Eliquis 2.5 mg by mouth twice daily for unspecified atrial fibrillation, but the January 2026 and February 2026 MAR contained no documented evidence of monitoring for bleeding. During interview, the DON confirmed there was no documented evidence of monitoring for signs and symptoms of bleeding while the resident was receiving Eliquis.
Infection Control Failures During Medication Pass, Wound Care, and Whirlpool Use
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. During medication administration observation on 02/26/2026 at 7:47 a.m., S5LPN did not perform hand hygiene before medication administration, between tasks during medication administration, or after medication administration. During the same observation, medication fell from Resident #30's mouth onto her shirt, and S5LPN picked up the medication with an ungloved hand and administered it to Resident #30. This occurred three times. The facility also failed to follow its Enhanced Barrier Precautions policy during wound care for Resident #11. On 02/23/2026 at 2:34 p.m., S9CNA assisted with turning and repositioning during wound care and exited Resident #11's room without doffing PPE. Interview with S3ADON confirmed Resident #11 had EBP precautions in place due to wounds, and S9CNA later re-entered the room in PPE. In addition, during observation on 02/23/2026 at 4:27 p.m., the whirlpool tub on the 400 hall was observed to have a brown colored substance and hair inside the pool, and S4CNA confirmed the tub was unclean and should have been cleaned after each use.
Unsanitary Resident Room Surfaces and Equipment
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for a resident when surveyors repeatedly observed unsanitary conditions in the resident’s room over three consecutive days. On 02/23/2026 at 10:00 a.m., 02/24/2026 at 9:00 a.m., and 02/25/2026 at 8:30 a.m., observations revealed a spilled substance on the bedside table and tube feeding pole used by the resident. Additional observation showed a black substance and grime on the resident’s air conditioning unit. During an interview on 02/25/2026 at 8:38 a.m., the housekeeper confirmed the presence of spills and splatters on the bedside table and tube feeding pole, and in a separate interview at 8:42 a.m., maintenance staff confirmed the black substance and grime on the air conditioning unit and that the air filter needed to be changed. These conditions demonstrate that the resident’s right to a safe, clean, comfortable, and homelike environment, including safe treatment and supports for daily living, was not maintained, as evidenced by the persistent spills on care-related equipment and visible grime and buildup on the room’s air conditioning unit.
Respiratory Equipment Not Stored or Changed as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for 2 residents reviewed for respiratory services. For Resident #31, who had diagnoses including pneumonia, reflux, anxiety, and dementia and a BIMS score of 10 indicating moderate cognitive impairment, the record included orders for Ipratropium-Albuterol inhalation solution as needed for cough and dyspnea and for nebulizer tubing to be changed every week on Friday. Observations on 02/24/2026 and 02/25/2026 showed the resident’s nebulizer mask lying uncovered on the window sill and not stored in a bag, and the tubing was dated 01/30/2026. During the observation, S5LPN confirmed the mask should be stored in a bag and the tubing should be changed weekly. For Resident #78, whose diagnoses included respiratory failure, the record included an order for oxygen at 2 liters per minute via nasal cannula every shift and an order to change oxygen tubing every week on Thursdays. Observations on 02/23/2026 and 02/24/2026 showed the resident receiving oxygen via nasal cannula with tubing dated 02/13/2026. During an observation with S8LPN, the tubing was still dated 02/13/2026, and S8LPN confirmed the oxygen tubing had not been changed weekly and should have been.
Pharmacist Failed to Identify Missing Bleeding Monitoring for Resident on Eliquis
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed a monthly drug regimen review that included the medical chart and identified irregularities related to monitoring prescribed medications for Resident #11. Resident #11 was admitted on 10/21/2025 and had diagnoses including atrial fibrillation, hypothyroidism, hyperlipidemia, schizophrenia, dementia, and depressive disorder. The quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment. The care plan identified the resident as at risk for bruising and bleeding related to anticoagulant therapy and included observing for signs and symptoms of bleeding. Physician orders included Eliquis 2.5 mg twice daily for atrial fibrillation, and the January and February 2026 MARs showed the medication was administered as ordered. However, there was no documentation that monitoring for signs and symptoms of bleeding was completed, and the monthly MRR dated 01/31/2026 did not document that the pharmacist addressed the facility's failure to monitor the resident while receiving Eliquis. During interview on 02/25/2026, the DON confirmed the pharmacist did not address this failure.
Failure to Timely Complete MDS Admission Assessment
Penalty
Summary
The facility failed to conduct a timely Minimum Data Set (MDS) admission assessment for a resident, identified as #238, among a sample of 26 residents. The resident was admitted on an unspecified date, and the admission MDS assessment was due by December 6, 2024. However, as of December 11, 2024, the assessment was still in progress and had not been completed or submitted to the Centers for Medicare and Medicaid Services (CMS). This deficiency was confirmed during interviews with the MDS Coordinator and the Director of Nursing, who both acknowledged the delay in completing and transmitting the required assessment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Arcadia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Ridge Nursing And Rehabilitation Center,llc | 0.5 mi | ★★★★★ | 3 | 0 |
| Alpine Skilled Nursing And Rehabilitation | 13 mi | ★★★★★ | 6 | 0 |
| Princeton Place-ruston | 16.6 mi | ★★★★★ | 6 | 0 |
| Presbyterian Village Of Homer | 16.9 mi | ★★★★★ | 0 | 0 |
| Ruston Nursing And Rehabilitation Center, Llc | 20.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.