Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Arbrook Plaza during CMS and state inspections, most recent first.
Incomplete Care Plans and Missing EBP Documentation: The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for multiple residents, and failed to update care plans to reflect EBP needs. Records showed several residents with conditions such as dementia, epilepsy, cerebral palsy, diabetes with neuropathy, dialysis dependence, pressure ulcer, G-tube, Foley, and dialysis port had no active EBP orders and no EBP notation in their care plans. Interviews confirmed that care plans were intended to guide resident care and that nursing staff were responsible for updating them.
A resident on EBP with a wound/incision and staples received perineal care from a CNA and RA without gowns during a high-contact care task. The room had an EBP sign requiring hand hygiene plus gown and glove use for activities such as changing briefs and providing hygiene, and multiple staff members, including the DON and Medical Director, stated gowns and gloves were required to prevent infection spread. The facility policy also required targeted gown and glove use for residents with wounds or indwelling devices.
A facility failed to complete person-centered care plans for three residents with significant medical and functional needs. The care plans did not reflect grab/assist bar use, the goal for having the bars on the beds, or prior interventions, and records lacked documented discussion of risks and benefits with the resident or RP. Observations showed the beds had grab/assist bars raised on both sides while the residents were resting, and one resident’s record also showed a bed rail assessment stating rails were not currently utilized or indicated despite a signed consent form.
Grab/assist bars were placed on the beds of four residents without the required assessment and, for some residents, without documented informed consent or a risks-and-benefits discussion with the resident or RP. The residents had significant medical and functional needs, including stroke, dementia, aphasia, weakness, fractures, and respiratory illness, and staff stated the facility policy required consent, DON approval, therapy assessment, and care plan review before the bars could be used.
Medication carts were found unsecured and unclean. An LVN left one med cart unlocked and unattended in the hallway, a med aide left bubble-pack medications on top of another cart while administering meds to a resident, and a third cart had brown and black sticky residue and dust in the medication cup compartments. Staff stated medication carts should be locked when not in use and kept clean for infection control.
A resident with a g-tube, cerebral palsy, and severely impaired cognitive skills was observed during med pass while his enteral feeding and water flushes were running. An LVN repositioned him by lowering the HOB without pausing the pump, then pulled him up and raised the HOB again. The LVN said she had been trained to stop the feeding before repositioning but forgot, and the DON confirmed the expectation was to pause feedings during repositioning or incontinent care.
A resident with dementia and moderate cognitive impairment had a small refrigerator in her room for family-brought soda, but there was no thermometer inside and no temperature log attached. Staff gave conflicting information about responsibility for monitoring room refrigerators, and the DON stated residents were not allowed to have refrigerators in their rooms. The facility also lacked a specific policy for personal refrigerators, while its Resident Personal Food Storage policy addressed only perishable food disposal.
A resident with encephalopathy, hyperlipidemia, and type 2 DM, who had memory problems and severe cognitive impairment, was observed in bed with the call light tied to the bed rail and the call button missing. Staff interviews showed the CNA, ADON, DON, and maintenance all recognized that call lights must be working and within reach, and maintenance stated she had been told the call light was broken before the observation.
The facility failed to maintain a sanitary and comfortable environment in the main dining room, affecting 10 residents. Observations showed an uncovered trashcan and a dirty vacuum cleaner left in the dining area during lunch service. Interviews with staff confirmed the expectation for cleanliness and proper equipment storage, as outlined in the facility's sanitation policy.
A facility failed to label and date an IV saline solution for a resident, risking infection and incorrect dosing. The resident, with multiple health issues, was receiving IV hydration for low blood pressure. The LVN admitted to the oversight, and the DON acknowledged the labeling should occur within 24 hours, as per facility policy.
Two residents in the facility were found with improperly stored respiratory equipment, including unbagged nasal cannula tubing and nebulizer masks touching unclean surfaces. The facility's staff failed to adhere to professional standards for storing respiratory equipment, as confirmed by interviews with the RN, ADON, DON, and ADMIN. The facility's policy on oxygen administration did not address proper storage, contributing to the oversight.
The facility failed to maintain an effective infection prevention and control program, impacting four residents and one quarter of water management. An LPN did not adhere to Enhanced Barrier Precautions while administering medication via a G-tube. Another resident experienced a breach in infection control during wound care, leading to potential contamination. The facility also failed to perform a quarterly water system flush, and a hospice CNA did not follow infection control protocols, risking cross-contamination.
The facility failed to ensure residents could exercise their right to vote, affecting eight residents who expressed interest in voting but were not approached by staff. Additionally, a resident's dignity was compromised during mealtime when a CNA stood over her while feeding, contrary to training that emphasized sitting at eye level. The facility lacked documentation and a policy to support voting rights, highlighting deficiencies in upholding resident rights.
Two residents in an LTC facility did not receive necessary nail care, leading to potential hygiene and quality of life issues. One resident with severe cognitive impairment and diabetes had long, untrimmed nails despite a podiatrist visit, while another resident with limited mobility had yellow, jagged fingernails and infected toenails. Facility staff failed to follow up on nail care needs, and the facility's policy on nail care was not adhered to.
A resident with limited range of motion did not receive timely physical therapy reevaluation, as required by facility policy. Despite the resident's need for extensive assistance and functional limitations, the facility failed to conduct a quarterly PT reevaluation after therapy ended. Interviews revealed that the resident and family were concerned about the lack of therapy services, with the DOR mistakenly believing the resident was refusing therapy. This oversight could risk further decline in the resident's mobility.
A facility failed to provide necessary behavioral health services to a resident with severe cognitive impairment and multiple diagnoses. Despite a physician's order for a psychiatric evaluation due to concerning behaviors, there was no documentation of the evaluation being completed. Interviews revealed a lack of communication and follow-up on the referral, with the social worker unaware of the incidents and not having submitted any referrals. The acting DON acknowledged the risk of harm if evaluations were not completed timely.
A facility failed to obtain heart rate parameters for Digoxin before administering it to a resident with heart conditions. The resident's care plan lacked necessary interventions for Digoxin toxicity, and staff interviews revealed communication and procedural breakdowns. The acting DON confirmed the need for verified parameters to prevent adverse effects.
A resident with lung cancer was not offered the influenza vaccine despite consenting to it upon admission. Facility staff interviews revealed a lack of communication and follow-through, resulting in the resident not receiving the vaccine, which she expressed she wanted due to her condition.
A facility failed to ensure consistent documentation of narcotic administration for a resident, leading to discrepancies between the narcotic count sheets and the MAR. The resident, with a history of knee infection and arthritis, required careful pain management. Staff interviews revealed that documentation practices were not consistently followed, potentially due to the resident's demanding behavior. Facility policies did not adequately address the need for consistent electronic MAR documentation.
A resident's family member filed a grievance alleging verbal abuse by a staff member, which the facility failed to report to authorities. The resident, who had dementia and required significant assistance, was allegedly yelled at and called stupid by a staff member. Despite staff interviews confirming such behavior as abuse, the Administrator deemed it a customer service issue, leading to a failure in reporting as per the facility's Abuse Prevention Program policy.
Incomplete Care Plans and Missing EBP Documentation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 8 of 9 residents reviewed. The deficiency was identified through interviews and record review and involved residents with diagnoses including epilepsy, dementia, cerebral palsy, diabetes with neuropathy, dependence on renal dialysis, pressure ulcer, gastrostomy status, and other conditions. The report states that the facility also failed to update each resident’s person-centered comprehensive care plan to reflect the need for EBP, and that this failure could place residents at risk of infection. Record review showed that Resident #1 had diagnoses including epilepsy, dementia, and a right femur fracture, but there was no active order for EBP and no notation of EBP in the care plan. The EBP list provided by the Administrator showed that Resident #1 had an incision with staples. Resident #2 had cerebral palsy, no active EBP order, and no EBP notation in the care plan, while the EBP list showed a G-tube. Resident #3 had a urogenital implant, no active EBP order, and no EBP notation in the care plan, while the EBP list showed a dialysis port. Resident #4 had epilepsy, no active EBP order, and no EBP notation in the care plan, while the EBP list showed a dialysis port. The remaining reviewed residents also lacked EBP-related orders and care plan documentation. Resident #5 had dementia and a G-tube on the EBP list; Resident #6 had diabetes with neuropathy and a dialysis port on the EBP list; Resident #7 had dependence on renal dialysis and a dialysis port on the EBP list; Resident #8 had a stage 3 sacral pressure ulcer and gastrostomy status, with the EBP list showing a G-tube and Foley; and Resident #9 had gastrostomy status, with the EBP list showing a G-tube and wound. During observation, the rooms of these residents were checked for EBP signs. Interviews with the Medical Director, MDS nurse, ADONs, DON, and Nurse Consultant reflected that care plans were used to guide resident care and that the MDS nurse and nursing staff were responsible for updating them, while the DON stated corporate said residents did not have to have specific orders and care planned for EBP.
Failure to Follow Enhanced Barrier Precautions During Perineal Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to follow enhanced barrier precautions during direct care for one resident. Resident #1 was an [AGE]-year-old male admitted and readmitted to the facility with diagnoses including epilepsy, unspecified dementia, and a right femur fracture healing routinely. The record review showed no active order for enhanced barrier precautions and no active care plan notation for them, although the facility’s enhanced barrier precautions list identified the resident as having an incision with staples. On 05/08/26, an observation at 8:25 AM showed an enhanced barrier precautions sign outside the resident’s room stating that staff must clean hands on entry and exit and must wear gloves and a gown for high-contact care activities, including changing briefs or assisting with toileting and providing hygiene. Later that day at 11:26 AM, CNA A and RA B provided perineal care to the resident without gowns. The report states the resident was on enhanced barrier precautions at the time of the observation. During interviews, the Medical Director, DON, LVN C, ADON D, ADON E, the Nurse Consultant, CNA A, and RA B all acknowledged that gowns and gloves were required for care of residents on enhanced barrier precautions to prevent spread of infection. CNA A stated she saw the sign only after changing the resident’s brief, and RA B stated she should have worn a gown, gloves, and mask but did not. The facility policy dated 04/2024 stated enhanced barrier precautions require targeted gown and glove use during high-contact resident care activities for residents with wounds and/or indwelling medical devices.
Care Plans Missing Bed Rail and Grab Bar Details
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents so that the plans reflected the use of grab/assist bars, the goal for having grab/assist bars on the beds, and the interventions that had previously been attempted. The deficiency was identified through observation, interview, and record review for residents with significant medical and functional needs, including stroke, diabetes with chronic kidney disease, dysphagia, respiratory failure, fractures, dementia, weakness, and fall risk. For one resident, the record showed a BIMS score of 11, moderate cognitive impairment, and extensive assistance needs for mobility and activities of daily living, including dependence for transfers and walking. The care plan reviewed for that resident did not include any indication of discussion of risks and benefits with the resident or responsible party, and it had no reference to an assessment completed for bed rails or grab/assist bars. For another resident, the record showed diagnoses including vertebral fracture, muscle wasting, dysphagia, dementia, heart failure, and fall history. The care plan included ADL assistance and fall-risk interventions, but it also had no indication of discussion of risks and benefits with the resident or responsible party and no reference to an assessment completed for bed rails or enabler bars. For the third resident, the record showed diagnoses including cancer of the head, face, and neck, critical illness myopathy, acute respiratory failure with hypoxia, osteoarthritis, acute kidney failure, and syncope. The resident had a BIMS score of 14, but functional ability information was not available in the reviewed MDS. The care plan included fall-risk, ADL assistance, and pain interventions, yet it also had no indication of discussion of risks and benefits with the resident or responsible party and no reference to an assessment completed for bed rails or grab/assist bars. A separate bed bar/side rail assessment for this resident stated that bed rails/bar were not currently utilized or indicated, yet an informed consent form for use of bed rails was signed. Observations showed the beds for all three residents had grab/assist bars raised on both sides while the residents were resting in bed, and the bars remained in place on later observation.
Grab/Assist Bars Placed Without Required Assessment and Consent
Penalty
Summary
The facility failed to assess the appropriateness of grab/assist bars and failed to review the risks and benefits with the resident or resident representative and obtain informed consent before the bars were placed on the beds of four residents. The report states that the facility also failed to have evidence of assessment for risk of entrapment and ability to safely use the grab/enabler bars for three of the residents reviewed. These findings were identified through observations, interviews, and record review. Resident #1 had multiple significant diagnoses including a cerebrovascular accident, diabetes with chronic kidney disease, dysphagia, respiratory failure, generalized weakness, abnormal posture, and fractures of the cervical spine and left humerus. The resident’s MDS showed moderate cognitive impairment and extensive assistance needs for mobility and ADLs. The care plan contained no indication of a discussion of risks and benefits of grab/assist bars, no reference to a bed rail assessment, and the record review found no signed consent or verbal permission for the 1/8 bed rails/grab/assist bars. Resident #32 had diagnoses including stroke with hemiplegia, epilepsy, aphasia, apraxia, dysphagia, and coordination deficits, and the MDS showed severe cognitive impairment with extensive assistance needs. The care plan included a focus area for use of bed bar/assist rail and the Bed Bar/Side Rail Evaluation showed assessments were completed, but the electronic record contained no consent for the 1/8 bed rails/grab/assist bars signed by the resident or representative or noted verbal permission. Resident #51 had diagnoses including a lumbar compression fracture, muscle wasting, weakness, dysphagia, dementia, and fall history; the care plan had no indication of a risks-and-benefits discussion or a completed bed rail assessment, although the record contained an informed consent form initialed by the resident and a Bed Bar/Side Rail Evaluation stating bed bars were not currently utilized or indicated. Resident #111 had diagnoses including malignant neoplasm of the head, face, and neck, critical illness myopathy, acute respiratory failure with hypoxia, acute kidney failure, and syncope; the care plan had no indication of a risks-and-benefits discussion or a completed bed rail assessment, although the record contained a Bed Bar/Side Rail Evaluation stating bed bars were not currently utilized or indicated and an informed consent form signed by the resident or representative. Observations on 01/13/2026 and 01/14/2026 showed the beds of Residents #1, #32, #51, and #111 had grab/assist bars raised on both sides while the residents were resting in bed, and Resident #1’s bars remained on the bed after discharge. Staff interviews stated that the facility policy required a signed consent form, discussion of risks with the resident and responsible party, DON approval, therapy assessment, and care plan inclusion before bed rails or grab/assist bars could be placed. Staff also stated that assessments were needed and described risks such as head injury, skin tears, bruising, entrapment, strangulation from cords, and hazards getting in and out of bed.
Medication carts left unsecured and unclean
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in locked compartments and kept under proper control when Med Cart #1 was observed unlocked and unattended on the 400 hallway. LVN B was seen walking toward the cart and then pushing the lock mechanism into the locked position. She stated the cart belonged to her, contained insulins, prescription pills, over-the-counter medications, and albuterol inhalers, and that she had forgotten to lock it after removing the key. She also stated the cart should always be locked when not in use so no one could get into it. The facility also failed to secure medications on Med Cart #2 during medication administration to a resident with unspecified encephalopathy, hyperlipidemia, and Type 2 diabetes. Med Aide D administered Eliquis, Clopidogrel, Furosemide, Glimepiride, and Carvedilol to the resident, then locked the cart but left the medication bubble cards on top of the cart while she went into the resident’s room. The resident dropped a pill, and Med Aide D bent down to look for it while the medications remained out of the cart and not in her direct line of sight. She stated she thought the surveyor was watching the cart and acknowledged that if medication is not in direct eye view, it should be locked inside the cart. Med Cart #3 was also observed in an unclean condition. The cart had brown and black sticky substance on the outside, brown dust particles inside the compartments that held medicine cups and water cups, and a belonging bag in the lower compartment next to the cups. The trash bag and lid to the trash can underneath the medicine cup compartment also had brown and black substances stuck on them. Med Aide E stated he had cleaned the cart the previous day but had not cleaned it that morning before using it. The ADON stated all staff using medication carts were responsible for keeping them clean and sanitary, and the DON stated all medications should not be left unattended and all medication carts should be kept clean for infection control.
Improper Positioning During Active Tube Feeding
Penalty
Summary
Appropriate care and services were not provided to prevent complications of enteral feeding for one resident with a gastrostomy tube. The resident had cerebral palsy, severely impaired cognitive skills for daily decision making, and required extensive two-person assistance with bed mobility and total dependence for dressing, toileting, and personal hygiene. He had physician orders for head-of-bed elevation at 30-40 degrees except for ADL care, g-tube flushes with 300 cc of water every 4 hours, and pump feeding at 40 cc/hr for 22 hours. His care plan for dysphagia also directed that the head of bed be elevated 30-45 degrees during feeding and for thirty minutes after tube feeding. During a medication administration observation, the resident was lying in bed with the g-tube feeding pump infusing and water flushes running. The LVN stated she was going to reposition the resident to administer medication, but she did not pause or switch off the feeding pump before lowering the head of the bed. She pulled the resident up using the bed sheet and then raised the head of the bed again. The LVN later stated she should have stopped the feeding before lowering the head of the bed and that she had been trained to do so, but forgot because she was nervous being watched. The DON stated the expectation was to pause the feeding when repositioning or providing incontinent care, and the Administrator stated nursing staff were expected to follow the process and procedure in place for resident safety. The facility policies reviewed did not address keeping the resident in the proper position with the head of bed elevated to 45 degrees with enteral feeding as ordered.
Missing Temperature Monitoring for Resident Room Refrigerator
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for one resident reviewed for a refrigerator in the room. Resident #4 was an older female admitted with a primary diagnosis of unspecified sequelae of cerebral infarction and a secondary diagnosis of dementia. Her admission MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and her care plan addressed memory, judgment, decision making, and thought process related to dementia. During observation, Resident #4 was in her room with family at bedside, and a small glass-door refrigerator was observed near the window with items visible inside. There was no thermometer inside the refrigerator and no temperature log attached to it. The resident's family member stated he had obtained the refrigerator a few weeks earlier so the resident could store her soda, and he said he set it to 40 degrees and monitored the temperature by the coolness of the items when visiting daily. Staff interviews showed CNA F was not aware of any resident room refrigerators, the Housekeeping Supervisor said nursing was responsible for monitoring room and med room refrigerators, and the DON stated residents were not allowed to have refrigerators in their rooms. Record review also showed the facility policy titled Resident Personal Food Storage stated nursing staff were responsible for discarding perishable food on or before the use-by date.
Broken Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a working call system was available and within reach for Resident #3. Resident #3’s record showed diagnoses including unspecified encephalopathy, hyperlipidemia, and type 2 diabetes, with the MDS reflecting memory problems, severely impaired cognitive skills for daily decision making, and dependence on staff for toileting, showers, and transfers. The care plan identified the resident as high risk for falls and directed staff to keep the call light within reach and encourage its use for assistance as needed. During observation, Resident #3 was in bed and could not communicate well, and the call light was tied to the bed rail with the call button missing. The resident did not answer questions about the call button. In interviews, a CNA stated the call light had been working previously and said she would report it to maintenance for replacement, while the ADON and DON stated CNAs and all staff were responsible for ensuring call lights were within reach and working. The maintenance person stated she had been notified before the observation that the call light was broken and said she replaced it after being informed again on 01/13/26. The facility policy stated the call light should be plugged in at all times and within easy reach of the resident.
Failure to Maintain Sanitary Dining Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in the main dining room, which serves 10 out of 25 residents. On the specified date, observations revealed that the dining room trashcan was not covered with a lid, and a vacuum cleaner with visible dirt and debris was left in the dining area where residents were waiting to be served lunch. This oversight in housekeeping and maintenance services could lead to an unsanitary and uncomfortable environment for the residents. Interviews with the housekeeping staff (HSKS) and the administrator (ADMIN) confirmed the expectations for maintaining cleanliness and proper storage of equipment. The HSKS acknowledged that the housekeeping staff was responsible for cleaning the dining room after each meal and ensuring trashcans were covered. The vacuum cleaner should have been stored in a locked housekeeping supply closet immediately after use. The ADMIN reiterated the facility's expectation for cleanliness and sanitation, emphasizing that any unsanitary concerns should be reported for correction. The facility's policy on sanitation, revised in December 2008, mandates that food service areas be kept clean and sanitary, with waste disposed of in tightly closed containers daily.
Failure to Label IV Fluids Poses Risk to Resident
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, identified as Resident #44, by not labeling and dating the IV solution at the time of administration. This oversight was observed on January 23, 2025, when the resident was receiving IV hydration due to low blood pressure. The resident, a male with a history of kidney failure, chronic pain, type 2 diabetes, anemia, hyperlipidemia, and cognitive impairment, was found with an undated saline solution bag and dressing. The lack of labeling posed risks for infections, incorrect dosing, and inadequate clinical monitoring. During an interview, the Licensed Vocational Nurse (LVN) admitted to forgetting to label the saline bag and dressing with essential information such as the resident's name, date, order amount, and time. The Director of Nursing (DON) stated that the bag should be labeled after 24 hours, and more detailed information should be added after 72 hours. The facility's policy on intravenous administration, revised in April 2009, requires documentation of the date and time of infusion, type and amount of solution, route and rate of administration, condition of the IV site, and any complications. However, these procedures were not followed, leading to the deficiency.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, leading to deficiencies in the storage and labeling of respiratory equipment. Resident #16, a cognitively intact male with COPD, was observed with his nasal cannula tubing unbagged and wrapped around a portable oxygen container when not in use. This was contrary to the physician's order, which required the nasal cannula tubing to be changed and labeled weekly. The resident reported using the portable oxygen the previous day, indicating that the equipment was not stored properly after use. Similarly, Resident #27, a female with acute respiratory failure and COPD, was found with her nebulizer mask and tubing improperly stored. The nebulizer machine and tubing were observed in a bag with parts hanging out and touching the chair cushion and floor. Additionally, the nasal cannula tubing and water bottle were not dated, as required by the physician's order. The resident could not recall when the equipment was last changed, and the RN on duty did not notice these issues during her rounds. Interviews with the RN, ADON, DON, and ADMIN confirmed that the facility's staff failed to adhere to professional standards for storing respiratory equipment. The staff did not ensure that the nasal cannula and nebulizer mask were bagged and labeled when not in use, which could lead to cross-contamination and infection. The facility's policy on oxygen administration did not address the proper storage of tubing, contributing to the oversight.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, impacting four residents and one quarter of water management. For Resident #33, the facility did not ensure that LVN E adhered to Enhanced Barrier Precautions (EBP) while administering medication via a G-tube. Despite being trained on EBP, LVN E neglected to wear a gown, which is a critical component of the protocol designed to protect residents with medical devices from infection. Resident #67 experienced a breach in infection control during wound care. LVN D and CNA H failed to maintain a sterile field, leading to potential contamination. CNA H placed a contaminated trash bag on a clean field with wound care items, and LVN D did not restart the procedure after noticing the contamination. This oversight posed a risk of infection and contamination to Resident #67, who had a surgical wound and a wound infection. The facility also failed to perform a quarterly water system flush, missing a critical step in their Legionella Water Management Plan. This lapse was attributed to a labor shortage and a transition in the Maintenance Director position. Additionally, Hospice CNA Q did not follow infection control protocols, placing soiled linen from Resident #23 on Resident #48's bed, risking cross-contamination. The facility's policies on hand hygiene and infection control were not adequately enforced, leading to these deficiencies.
Failure to Facilitate Voting and Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to exercise their right to vote, affecting eight residents. These residents expressed interest in voting for the upcoming election but reported that no staff had approached them to facilitate this process. Interviews with the residents revealed their dissatisfaction with not being asked about their voting preferences, and the facility lacked documentation to support any efforts made to assist residents in voting. The Activity Director claimed to have offered absentee voting and assistance to the residents, but there was no evidence to substantiate these claims. Furthermore, the Administrator admitted that the facility had never offered voting opportunities to residents, citing issues such as lack of current IDs and residents not being from the local area. Additionally, the facility failed to maintain the dignity of a resident during mealtime. A resident was observed being fed while in a Geri chair tilted at a 45-degree angle, with the CNA standing over her. The CNA acknowledged that she was trained to sit at eye level with residents while feeding them to ensure proper communication and dignity. The Administrator confirmed that staff were expected to sit at eye level with residents during feeding to maintain their dignity and ensure effective communication. The facility's policy on resident rights, revised in 2009, emphasizes treating residents with kindness, respect, and dignity, and ensuring they can exercise their rights to the fullest extent possible. However, the lack of action in facilitating voting and the improper feeding technique observed indicate a failure to uphold these standards. The absence of a policy related to voting rights further highlights the deficiency in supporting residents' rights as citizens.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary nail care for two residents, leading to potential risks to their personal hygiene and quality of life. Resident #9, a female with severe cognitive impairment and a history of Type 2 Diabetes Mellitus and paralysis, was observed with long, thick, yellowish-brown, and sharp nails on her left hand. Despite being resistant to care, the facility's staff did not follow up adequately after a podiatrist visit, resulting in the resident's nails remaining untrimmed. The facility's policy required that diabetic residents' nails be trimmed by nurses, but this was not adhered to, as the resident's nails were not addressed even after the podiatrist's visit. Resident #298, a male with limited mobility and a history of sepsis and rectal cancer, also did not receive proper nail care. His fingernails were observed to have a yellow substance underneath and jagged edges, while his toenails were yellow, curling, and one was infected. Despite the resident expressing a desire for his nails to be cut, the facility staff did not take appropriate action to address his nail care needs. The facility's policy on nail care was not followed, as the resident's nails were not cleaned or trimmed regularly, and the infection in his toenail was not promptly addressed. Interviews with facility staff revealed a lack of communication and follow-up regarding the residents' nail care. The Administrator and ADON acknowledged the responsibility of charge nurses and CNAs in ensuring nail care, but there was a failure to monitor and document the care provided. The facility's policy emphasized the importance of regular nail care to prevent infections and skin problems, but this was not implemented effectively, leading to the deficiencies observed in the care of Residents #9 and #298.
Failure to Provide Timely Physical Therapy Reevaluation
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase or maintain range of motion. The resident, a male with a history of gastrointestinal stromal tumor, muscle wasting, lack of coordination, and generalized muscle weakness, was admitted to the facility and required extensive assistance for various activities of daily living. Despite being dependent on staff and having functional limitations in range of motion, the facility did not complete a quarterly physical therapy reevaluation screening after the resident's physical therapy ended. This lapse in care could place the resident at risk for further decline in range of motion and mobility. Interviews revealed that the resident and his family were concerned about the lack of therapy services, with the family being informed that the facility was short-staffed and without a physical therapist earlier in the year. The Director of Rehabilitation (DOR) admitted that the resident had not been reevaluated for physical therapy because it was believed he was refusing therapy, despite the resident's statement to the contrary. The DOR also acknowledged that reevaluations were supposed to be done quarterly, but this was not followed through. The facility's policy stated that rehabilitative services would be provided as indicated by the MDS, but this was not adhered to in the case of the resident in question.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services, as evidenced by the lack of follow-up on a psychiatric evaluation referral. The resident, a male with severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and cognitive communication deficit, exhibited behaviors such as yelling, threatening, and refusing medication and food. Despite these concerning behaviors and a physician's order for a psychiatric evaluation, there was no documentation of the evaluation being completed in the resident's electronic health record. Interviews with facility staff revealed a lack of communication and follow-up regarding the psychiatric referral. The LVN believed the evaluation had been conducted, while the social worker was unaware of the resident's behavioral incidents and had not submitted any referrals since starting at the facility. The acting DON acknowledged the risk of harm to residents if psychiatric evaluations were not completed timely and indicated that the social worker was responsible for coordinating referrals. The facility's policy on referrals stated that social services personnel should coordinate most resident referrals with outside agencies, but this was not adhered to in this case.
Failure to Obtain Medication Parameters for Heart Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs for a resident. Specifically, the facility did not obtain heart rate or pulse parameters for the heart medication Digoxin before administering it to a resident. This oversight was identified during a review of the resident's medical records and medication administration records, which showed that the medication was administered without the necessary parameters being documented. The resident involved was an elderly female with a history of metabolic encephalopathy, paroxysmal atrial fibrillation, heart diseases, fluid overload, and high blood pressure. Despite these conditions, the resident's care plan did not include the heart medication Digoxin or any interventions or monitoring for potential Digoxin toxicity. During a medication observation, a Licensed Vocational Nurse (LVN) administered Digoxin to the resident without checking for the required parameters, although the resident's pulse was recorded at 108 using a pulse oximeter. Interviews with facility staff revealed a breakdown in communication and procedure. The LVN responsible for administering the medication acknowledged the lack of parameters and admitted to not seeking clarification from the doctor or the Assistant Director of Nursing (ADON). The admitting nurse also faced challenges in obtaining complete orders from the resident's previous facility, which contributed to the oversight. The acting Director of Nursing (DON) confirmed that parameters should have been verified and documented, and that the absence of such parameters could lead to adverse medication effects.
Failure to Administer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to ensure that Resident #299's medical record included documentation indicating that the resident or her representative was provided education regarding the benefits and potential side effects of the influenza immunization. Additionally, the facility did not document whether the resident received the influenza immunization or did not receive it due to medical contraindications or refusal. Resident #299, a [AGE] year-old female with a primary diagnosis of malignant neoplasm of an unspecified part of the adrenal gland, was admitted to the facility and had intact cognition as indicated by a BIMS assessment score of 15. Despite e-signing an informed consent for the influenza vaccination, the resident was not offered the vaccine, which she expressed she wanted due to her lung cancer. Interviews with facility staff revealed a lack of communication and follow-through regarding the administration of the influenza vaccine. LVN M stated that she did not remember asking Resident #299 if she wanted the flu vaccine, and the ADON mentioned that the concierge usually handled the paperwork and consents. The CNA responsible for the admission packet did not recall asking Resident #299 about the vaccine, despite the resident marking yes on the consent form. The acting DON confirmed that residents were supposed to receive vaccines within the first few days of admission, but this did not occur for Resident #299, potentially increasing her susceptibility to the flu.
Inconsistent Documentation of Narcotic Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for Resident #2, as evidenced by discrepancies in the documentation of narcotic medications. Specifically, the narcotic count sheets showed more doses of oxycodone signed out than what was documented as administered on the Medication Administration Record (MAR) on several occasions. This inconsistency was noted on 05/16/24, 05/28/24, and 05/30/24, where the count sheets indicated more frequent dispensing of oxycodone than the MAR reflected as administered to the resident. Resident #2, a male with a history of infection in his knee prosthesis, arthritis, legal blindness, and muscle spasms, was admitted to the facility and later discharged to the hospital. His pain management included scheduled and PRN pain medications, with a noted frequency of pain that limited his rehabilitation participation. Despite the need for careful pain management, the facility's documentation practices were inconsistent, potentially leading to medication errors. Interviews with facility staff, including LVNs and the DON, revealed that it was standard practice to document narcotic administration in both the electronic MAR and the narcotic count sheet. However, discrepancies in documentation were attributed to oversight, possibly due to the resident's demanding behavior. The facility's policies on controlled substances and documentation did not adequately address the need for consistent electronic MAR documentation, contributing to the observed deficiencies.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, as required by regulations. A grievance was filed by a family member on behalf of a resident, alleging that a staff member yelled at the resident, told her to go back to sleep, and called her stupid. Despite the grievance, the facility did not report this incident to the appropriate authorities, as the Administrator considered it a customer service issue rather than abuse. This decision was made despite interviews with staff members who confirmed that such behavior would be considered verbal abuse. The resident involved was an elderly female with dementia, cardiac pacemaker, insomnia, and anxiety disorder, who required substantial assistance with daily activities and was always incontinent. The grievance was documented by the Social Worker, who mistakenly noted that the staff member involved had been terminated, although no staff member was identified. The Administrator later clarified that the termination was an error and that the grievance was misunderstood and combined with another issue. Interviews with various staff members, including CNAs and the DON, indicated that yelling or calling a resident names would be considered abuse. However, the Administrator maintained that the incident did not constitute abuse, as it was presented as a customer service issue by the family. The facility's Abuse Prevention Program policy requires the identification, assessment, investigation, and reporting of all possible incidents of abuse, which was not adhered to in this case.
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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) |
|---|---|---|---|---|
| Town Hall Estates Arlington, Inc. | 0.6 mi | ★★★★★ | 1 | 1 |
| Matlock Place Health & Rehabilitation Center | 3.8 mi | ★★★★★ | 10 | 2 |
| Avir At Arlington | 4.5 mi | ★★★★★ | 13 | 3 |
| Green Oaks Nursing & Rehabilitation | 4.7 mi | ★★★★★ | 1 | 0 |
| Viridian Wellness & Rehabilitation | 4.7 mi | — | 41 | 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.