Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Serenity Spring Senior Living At Arlington during CMS and state inspections, most recent first.
The facility failed to ensure the QAPI group had the required members and met as required because the medical director did not attend multiple QAPI meetings. Review of sign-in sheets showed the MD was absent from several meetings, and the facility could not locate some of the sign-in sheets. The Administrator and Interim DON confirmed the missing attendance and documentation.
Infection control standards were not followed during medication administration when an LPN performed multiple resident care tasks without hand hygiene between tasks and placed a cup of medication on the floor before giving it to a resident. The facility also had no infection surveillance completed for the year reviewed, and physician-ordered CP and EBP signage was not posted correctly for two residents. In addition, staff did not wear the required gowns during EBP wound care and catheter care for two residents.
Failure to monitor antibiotic use and follow McGeer's criteria before antibiotics were given. Review of the infection control binder showed no ongoing antibiotic stewardship review for several months, and the IP stated that before she was hired, McGeer's criteria were not being completed and antibiotics were given per MD orders. She also verified that infection control documentation for earlier months was later completed by backdating records.
The facility failed to ensure CNAs received the required 12 hours of annual in-service education. Review of three CNA personnel files showed no evidence of training hours since the last recertification survey for each CNA, and the HRM confirmed the missing annual in-servicing during interview.
Resident Council concerns were not timely addressed or reported back to residents. Repeated complaints were raised that residents were being left on the toilet too long and that night-shift call light response times were longer than desired. A resident stated no dept head or staff member had explained what had been done, and the AD verified the facility could not locate documentation of follow-up to the nursing concerns.
A resident with an indwelling catheter related to neurogenic bladder was observed in the dining room with the foley bag hanging from the wheelchair without a privacy cover and urine visible in the bag. The care plan called for a privacy bag and keeping the bag off the floor, and a CNA confirmed the privacy bag was not in place. A later observation showed the same issue again.
Care plans failed to reflect current resident needs for three residents. One resident had ESBL precautions and daily wound care orders, another had ESBL with an active EBP isolation order, and a third had a PICC line for IV ertapenem for osteomyelitis, but none of these needs were included in the care plans. The MDS Nurse and DON confirmed the missing care plan items.
Care plan failed to include an ordered fall intervention for a resident at risk for falls. The resident had fractures of the L humerus and L femur, confusion, deconditioning, altered gait, and balance issues. The chart included a physician order for Dycem to the recliner every shift for fall prevention, but the care plan listed other fall interventions and did not include the Dycem order. The Interim DON verified the missing intervention.
A resident with left hand, elbow, and wrist contractures had orders for a left palm protector to be applied in the morning and removed at bedtime, but observations showed the device was often not on the resident and was found on the dresser. The resident stated aides did not always apply it, denied refusing care, and a CNA later confirmed the palm protector was not in place before applying it after the resident agreed.
A resident with a PICC line and multiple chronic conditions, including dementia and respiratory failure, had no care plan entry, no active orders, and no MAR/TAR documentation for PICC dressing changes or flushes. The PICC dressing was observed dated from weeks earlier, and the DON confirmed the orders did not include dressing changes or flushes even though PICC dressings should be changed weekly and the line flushed before and after IV meds per policy.
Three opened insulin pens on a med cart were found without open dates, including insulin lispro, Lantus, and Novolog for three residents. The facility also failed to properly dispose of expired insulin pens, and policy review showed insulin should be checked for expiration and dated after opening.
Incomplete TAR documentation was identified for two residents with complex medical needs, including wound care, behavior monitoring, UTI monitoring, Foley care, skin protection, oxygen saturation, and other ordered treatments. The TARs showed repeated missed documentation on day and night shifts, and the Interim DON verified the missing entries were a pattern on night shift. The facility policy required all services provided and changes in condition to be documented in the medical record.
The facility failed to date and cover open food products in the kitchen, potentially affecting all 33 residents. Observations revealed undated and uncovered items in the dry storage area, walk-in refrigerator, walk-in freezer, and reach-in refrigerator. The Dietary Manager confirmed these findings, which were against the facility's policy.
The facility failed to implement an appropriate Legionella water management program, including chlorine residual testing and flushing of stagnant water, since November 2023. The maintenance director position was vacant for several months, and interviews confirmed the absence of necessary prevention, detection, and control measures. Five unoccupied resident rooms were identified as part of the issue.
The facility failed to complete advanced directives for six residents and a comprehensive care plan for one resident receiving hospice services. Despite having physician orders for do not resuscitate comfort care (DNRCC) or DNRCCA, the residents lacked corresponding care plans. The DON confirmed these omissions during interviews.
The facility failed to ensure proper communication with the dialysis center for a resident requiring dialysis services. The resident's medical record and care plan lacked critical information, and dialysis communication forms were inconsistently filled out, missing 19 out of 25 dialysis days. Staffing issues were cited as a contributing factor.
QAPI Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure the QAPI group had the required members and met at least quarterly because the medical director did not attend QAPI meetings on 11/25, 12/25, 01/26, 02/26, and 03/26. Review of QAPI sign-in sheets showed the medical director’s absence on those dates, and the facility was unable to locate the sign-in sheets for 01/26 and 03/26. During interview, the Administrator stated he provided all QAPI sign-in sheets he could locate, and the Interim DON confirmed the medical director should have attended the 01/26 meeting but the sign-in sheet could not be found. The facility census was 44.
Infection Control and Precaution Signage Failures
Penalty
Summary
The facility failed to implement infection control standards during medication administration for seven residents observed receiving medications and treatments. During observation, an LPN took vital signs on five residents, gave oral medications to five residents, administered a lidocaine patch to one resident, gave eye drops to one resident, administered insulin to two residents, and checked blood sugar on two residents while wearing gloves but not performing hand hygiene between tasks. The LPN also placed a cup of water mixed with MiraLAX on the floor before giving a resident a drink from it after administering pills in pudding. In interview, the LPN verified hand hygiene was not completed during these medication administration tasks and stated the hand sanitizer had been removed from the medication cart and placed at the nurse's station. The facility also failed to complete infection surveillance. Review of the infection control documentation for 2026 showed no infection surveillance had been completed. The NM who served as the IP stated she was hired in May 2026 and that before her hire no one had been in the IP role or completing infection surveillance. She further verified that documentation from January 2026 through before May 2026 was completed in July 2026 because she had to go back and complete it, and she confirmed she was backdating the infection control documentation. The facility policy required the IP to conduct ongoing surveillance for HAIs and other significant infections. The facility did not follow physician-ordered precautions for residents on CP and EBP. One resident had an order for CP due to ESBL in urine, but observations showed no CP sign posted at the door and an EBP sign was posted instead; the DON verified the resident had an EBP sign even though the order was for CP. Another resident had an order for EBP due to ESBL in urine, but observations on two separate occasions showed no EBP signage on the door, and the IDON verified the resident should have had EBP signage. In addition, two residents requiring EBP did not have the required PPE used during care: one resident's wound care was performed by an RN and CNA wearing gloves but not gowns, and another resident's foley catheter care was provided by a CNA wearing gloves but not a gown. Both staff members verified they did not wear gowns during the care.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to ensure McGeer's criteria and antibiotic stewardship were followed before antibiotics were administered. Review of the infection control binder showed that from January 2026 through June 2026, the facility did not conduct ongoing review for antibiotic stewardship. The Nursing Manager, who was also the Infection Preventionist, stated she was hired in May 2026 and that before her hire no one had been completing McGeer's criteria for infections, and antibiotics were given per physician orders. She also stated she was trying to go back to January 2026 and complete the infection control documentation for the year because there had been no monitoring of infections or antibiotics in place. She further verified that documentation completed before May 2026 and back to January 2026 was completed in July 2026 by backdating the infection control records.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants (CNAs) had the required 12 hours of annual in-service education. Review of three CNA personnel files showed that CNA #109, hired on 04/30/26, had no evidence of any training hours since the last recertification survey on 04/18/24. CNA #110, hired on 05/28/26, also had no evidence of any training hours since the last recertification survey on 04/18/24. CNA #162, hired on 06/18/25, likewise had no evidence of any training hours since the last recertification survey on 04/18/24. During interview on 04/12/25 at 2:01 P.M., the Human Resource Manager confirmed that CNAs #109, #110, and #162 did not have the required 12 hours of annual in-servicing.
Resident Council Concerns Not Timely Addressed
Penalty
Summary
The facility failed to respond in a timely manner to concerns raised in Resident Council meetings and failed to report to the council the steps taken to rectify those concerns. Review of Resident Council minutes showed repeated complaints over three consecutive meetings that residents were still being left in the bathroom on the toilet for too long, including concerns that some residents were still being left on the toilet "here and there." This affected six residents who regularly attended Resident Council meetings in a facility census of 44. During interview, a resident stated that the council had concerns about being left on the toilet too long and that call light times on night shift were longer than they liked. The resident also stated that no department head or staff member had come to let them know what had been done to address the concerns. The Activity Director stated that copies of the council minutes were given to each manager and that managers came up with an action plan, but also verified that repeated concerns continued to be brought to the meetings and that the facility could not provide or locate documentation showing follow-up to the nursing concerns identified in the three consecutive Resident Council meetings. The facility policy stated that a Resident Council Response Form would be used to track issues and their resolution, and that the department related to the issue was responsible for addressing the items of concern.
Uncovered Foley Bag Visible in Dining Room
Penalty
Summary
The facility failed to ensure a dignity bag was placed on the foley catheter bag for Resident #46, who was admitted with diagnoses including neuromuscular dysfunction of the bladder and retention of urine. The care plan dated 09/10/21 identified an indwelling catheter related to neurogenic bladder and included interventions to use a privacy bag and keep the bag off the floor. During observation in the dining room, the resident’s catheter bag was hanging from the wheelchair uncovered, with urine visible in the bag. A CNA confirmed the privacy bag was not on the resident’s foley and that urine was visible while the resident was in the dining room. A follow-up observation later showed the resident again in the dining room with the foley bag hanging on the wheelchair without a privacy cover and urine visible in the bag. The facility policy titled Dignity stated that staff are expected to promote dignity and assist residents by helping them keep urinary catheter bags covered.
Care plans did not reflect current ESBL, wound, and PICC line needs
Penalty
Summary
The facility failed to ensure comprehensive care plans reflected residents’ current status for three residents reviewed. Resident #15 was admitted with diagnoses including cognitive communication deficit, cerebral infarction, acute kidney failure, and adult failure to thrive. Physician orders included enhanced barrier precautions (EBP) for ESBL and daily wound care to the left lower extremity, but the care plan dated 07/01/26 did not include either EBP or the left lower extremity wound. During interview, the MDS Nurse verified there was no care plan for EBP or the wound. Resident #4 had diagnoses including ESBL, chronic kidney disease, and malignant neoplasm of peritoneum, with a quarterly MDS showing intact cognition and need for assistance with toileting, dressing, bathing, and supervision with walking. The resident also received antibiotic medication and had an active physician order for EBP isolation, but the care plan dated 06/23/26 did not address ESBL or EBP. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, acute and chronic respiratory failure with hypoxia, systolic heart failure, GERD, and dementia. A significant change MDS showed moderately impaired cognition, and physician orders included ertapenem for osteomyelitis, but there were no active orders for PICC line care, dressing changes, or flushes. The care plan dated 06/01/26 did not include the PICC line, and observation confirmed the PICC line was present and dated 06/27/26; the DON verified it was not included in the care plan.
Care Plan Missing Ordered Fall Intervention
Penalty
Summary
The facility failed to ensure the care plan was updated to include fall interventions for one resident. Resident #10 was admitted on 04/26/24 with diagnoses including displaced fracture of the medial condyle of the left humerus and unspecified fracture of the left femur. The medical record showed a physician order for Dycem to the recliner for fall prevention every shift for safety/prevention of falls, and the resident’s care plan dated 04/26/24 identified the resident as at risk for falls related to confusion and deconditioning, with altered gait and balance. The care plan included interventions such as appropriate footwear, avoiding clothing that was a fall risk, a wheelchair with an anti-rollback device, and keeping the door open, curtain pulled back, bed in lowest position, and a floor mat at bedside. However, the care plan did not include any intervention for the ordered Dycem to the recliner for fall prevention every shift. During interview, the Interim DON verified that no intervention for Dycem in the recliner per physician order was located. The facility policy stated that staff, with input from the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors for each resident at risk or with a history of falls.
Failure to Apply Ordered Palm Protector
Penalty
Summary
The facility failed to ensure a left palm protector was applied as ordered for a resident with diagnoses including contracture of the left hand, left elbow, and left wrist. The resident’s record showed physician orders to check the left hand contracture daily for skin breakdown and to provide the left palm protector to the left hand, applying it in the morning and removing it at bedtime. The care plan also identified potential for skin impairment related to debility and limited use of the left side and included the same palm protector intervention. During observation and interview, the resident stated the aides were supposed to put the palm protector on in the morning and remove it at night, but that they did not always do so, and she denied refusing care. The palm protector was observed on the dresser while the resident was in bed without it on, and a CNA later confirmed it was not on the resident and applied it after the resident said yes. Additional observations later showed the resident resting in bed again without the palm protector on her left hand.
PICC Line Dressing and Flushes Not Managed per Standards
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids when it did not ensure a PICC line dressing was changed according to professional standards of practice and did not ensure the PICC line was flushed according to professional standards of practice for one resident. Resident #3 was admitted on 01/22/25 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, acute and chronic respiratory failure with hypoxia, hyperlipidemia, systolic heart failure, gastro-esophageal reflux disease without esophagitis, and dementia. A significant change MDS assessment showed moderately impaired cognition with a BIMS score of 10. Review of the care plan showed the PICC line was not included. Physician orders included Ertapenem Sodium 1 gram IV daily for osteomyelitis, but there were no active orders for the PICC line, PICC dressing changes, or PICC flushes. The MAR/TAR for July 2026 had no documentation of PICC dressing changes or flushes. On observation, the PICC line dressing was dated 06/27/26, and an LPN verified that date. The DON confirmed the physician orders did not include dressing changes or flushes for the PICC line and stated PICC line dressings should be changed weekly and flushes should be given before and after all medications administered through the PICC line. Facility policy stated the catheter should be flushed and aspirated for blood prior to each infusion and flushed after each infusion.
Undated and Expired Insulin Pens on Medication Cart
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles when three opened insulin pens on the 200-hall medication cart were found without an open date during observation and concurrent interview with RN #107. The undated pens were Resident #9's opened and used insulin lispro, Resident #14's opened and used Lantus, and Resident #27's opened and used Novolog. The report also noted that the facility failed to properly dispose of expired insulin pens. Manufacturer instructions reviewed for insulin lispro, insulin glargine (Lantus), and insulin aspart (Novolog) stated the pens should be used for a limited period after first use or opening, and the facility policy required checking expiration dates and recording the expiration date and time on a new vial or following the manufacturer's recommendations after opening.
Incomplete TAR Documentation for Ordered Treatments and Monitoring
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for two residents reviewed. For one resident with diagnoses including cognitive communication deficit, cerebral infarction, acute kidney failure, and adult failure to thrive, physician orders included wound care to the left lower extremity, behavior monitoring with documentation of non-pharmacological interventions, moisture barrier ointment, contracture monitoring to the right hand, and monitoring for signs and symptoms of UTI with UA/culture if indicated. Review of the TAR showed multiple missing entries on night shift in June and July 2026 for these ordered treatments, and no documentation for the left lower extremity wound care on two July dates. For the second resident with diagnoses including neuromuscular dysfunction of bladder, COPD, spinal stenosis, constipation, major depressive disorder, chronic pain, and urinary retention, physician orders included catheter drainage bag changes, Foley basin changes, dry skin barrier ointment, enhanced barrier precautions, Foley catheter care every shift, ROHO cushion use, skin sleeves, BLE washing and lotion with tubi-grips, Foley output monitoring, nebulizer cleaning, and oxygen saturation monitoring. Review of the TAR showed multiple treatments not signed off as completed in June and July 2026, including catheter-related care, skin care, positioning/support items, BLE care, Foley output documentation, oxygen saturation documentation, and nebulizer cleaning. During interview on 07/09/26, the Interim DON verified the missing TAR documentation for both residents and stated it was a pattern on night shift. The facility policy titled Charting and Documentation, revised July 2017, stated that all services provided to the resident and changes in condition shall be documented in the medical record so the interdisciplinary team can communicate regarding the resident's condition and response to care.
Failure to Date and Cover Open Food Products
Penalty
Summary
The facility failed to ensure open food products were dated and covered in the kitchen, potentially affecting all 33 residents who received food from the kitchen. During an observation, it was found that five bags of open pasta in the dry storage area were not dated. In the walk-in refrigerator, two trays of mandarin oranges were not covered or dated, and two bags of mozzarella cheese were open with no date. In the walk-in freezer, one bag of Salisbury steak was open with no date. Additionally, in the reach-in refrigerator, one container each of ham, strawberries, and dill pickles were not dated. The Dietary Manager confirmed these findings and stated that food is typically dated upon delivery. The facility's policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, and dry foods to be labeled and dated when stored in bins.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to have an appropriate Legionella water management program in place, which had the potential to affect all 33 residents. The most recent documentation revealed that the facility had not conducted chlorine residual testing since November 2023, and there was no evidence of flushing stagnant water except for monthly inspections of the eyewash stations. The maintenance director position had been vacant from December 2023 until it was filled in early April 2024. Interviews with the Administrator and Regional Director of Operations confirmed the absence of Legionella prevention, detection, and control measures, including a risk assessment, facility mapping of water sources, flushes, or testing. Five unoccupied resident rooms were identified as part of the issue. The facility's policy on the Legionella Water Management Program, revised in October 2023, outlined the need for a detailed description and diagram of the water system, identification of areas that could encourage the growth and spread of Legionella, and other waterborne pathogens. However, the facility did not adhere to these guidelines. The CDC guidance on water management programs emphasizes the importance of continuous review and the establishment of a water management program team, among other steps, to minimize the growth and transmission of Legionella. The facility's failure to implement these measures led to the identified deficiency.
Failure to Complete Advanced Directives and Comprehensive Care Plans
Penalty
Summary
The facility failed to complete advanced directives for six residents and a comprehensive care plan for one resident receiving hospice services. Resident #22, who was admitted with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and palliative care, did not have advanced directives or a comprehensive care plan for hospice services. The Director of Nursing (DON) confirmed the absence of these care plans during an interview. Similarly, Resident #2, with diagnoses including end-stage renal disease and dementia, had a physician order for do not resuscitate comfort care arrest (DNRCCA) but lacked a corresponding care plan for advanced directives. The DON verified this omission as well. Other residents, including Resident #15 with chronic obstructive pulmonary disease and dementia, Resident #24 with Alzheimer's disease and behavioral disturbances, Resident #28 with severe cognitive impairment and chronic respiratory failure, and Resident #30 with chronic pain syndrome and chronic kidney disease, also lacked care plans for their advanced directives despite having physician orders for do not resuscitate comfort care (DNRCC) or DNRCCA. The facility's policy on comprehensive person-centered care plans, revised in March 2022, mandates the inclusion of services to maintain the resident's highest practicable well-being, which was not adhered to in these cases.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure proper communication between the facility and the dialysis center for a resident requiring dialysis services. The medical record for the resident, who was cognitively intact and independent in activities of daily living, did not include the dialysis center's address and phone number. The care plan also lacked this critical information. Additionally, the facility did not consistently fill out the dialysis communication/referral forms, missing them on 19 out of 25 dialysis days since the resident's admission. This inconsistency was confirmed by the Director of Nursing (DON) and the Dialysis Registered Nurse (RN), who cited staffing issues as a contributing factor. The facility's policy on the care of residents with end-stage renal disease, which includes agreements on how care will be managed and information exchanged, was not adhered to. The DON verified that the communication forms were often incomplete or not returned by the dialysis center, and the resident's face sheet did not include the necessary dialysis center information. Despite having a plan to improve communication, the facility failed to maintain consistent and accurate communication with the dialysis center, as required by their policy.
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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 Arlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fox Run Manor | 10.5 mi | ★★★★★ | 23 | 0 |
| Birchaven Retirement Village | 10.5 mi | ★★★★★ | 5 | 0 |
| The Manor At Greendale | 11.2 mi | ★★★★★ | 0 | 0 |
| Vancrest Of Ada | 12 mi | ★★★★★ | 0 | 0 |
| Mennonite Memorial Home | 12.3 mi | ★★★★★ | 0 | 0 |
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