Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arlington Residence And Rehabilitation Center during CMS and state inspections, most recent first.
Unclean Resident Rooms and Shower Room: Multiple resident rooms on the Sunflower Hall and one shower room were observed with stains, built-up dirt, tissue debris, and stained privacy curtains. Housekeeping staff and the Housekeeping Supervisor stated they were responsible for cleaning the entire rooms and shower area, and the Administrator stated the rooms needed to be thoroughly cleaned because they should be homelike for residents.
Care plans for three residents were incomplete. One resident with an indwelling catheter had a physician order for Foley/Suprapubic catheter care, but no catheter care plan was documented. A second resident identified as a fall risk had a bed in the lowest position and a fall mat in place, but those interventions were not included in the care plan. A third resident’s care plan did not reflect smoking status even though the smoking assessment showed tobacco use and staff confirmed the resident was still smoking.
A resident with a fall-risk care plan intervention and another resident with similar fall-risk needs were observed using a scoop mattress without physician orders. Two residents had inaccurate or outdated smoking assessments, one resident had chewing tobacco in the room despite staff not recognizing smokeless tobacco use, and a container of odor neutralizer with chemical warnings was left accessible in a resident’s room.
Medications and barrier creams were found left accessible in resident rooms instead of being secured in locked storage. A roll-on analgesic was observed on one resident’s overbed table, zinc oxide was left on another resident’s table beside food and on a drawer visible from the hallway, and two barrier cream sachets, including one opened, were found on a third resident’s side table. The affected residents had diagnoses including dementia, Alzheimer’s disease, bipolar disorder, cognitive impairment, and incontinence, and the record showed no self-administration assessments for the topical products involved.
Kitchen Food Safety and Storage Deficiencies: The Dietary Manager was observed in the kitchen near food being cooked without a head cover, and a vendor making repairs near the food was not wearing a beard cover. The ice machine had reddish stains inside, several frozen vendor items were not dated with the month, day, and year received, and the deep fryer had light brownish substances floating in the oil. The Dietary Manager stated she forgot to replace her hairnet after leaving the kitchen, forgot to have the vendor wear a beard cover, believed the year was not needed on stored food, and did not think the inoperable fryer needed cleaning.
Infection Control Failures During Resident Care and Blood Sugar Monitoring: Staff were observed failing to follow hand hygiene, glove-changing, and PPE practices during care for residents with incontinence, a wound on EBP, and blood sugar monitoring. A CNA did not change gloves after cleaning a soiled area, another CNA did not wash hands before gloving, did not wear a gown, kept gloves in a pocket, and did not sanitize hands when changing gloves, and an LVN checked a resident’s BS without sanitizing hands first.
Call lights were not kept within reach for two residents whose care plans identified them as at risk for falls and required the call light to be accessible. One resident with severe cognitive impairment had a call light on the floor behind a side table, and another resident with weakness, visual loss, and chronic pain had his call light under a roommate’s bed. Staff interviews confirmed the call lights were supposed to remain accessible at all times so residents could summon assistance.
Failure to Protect Resident Privacy and Confidentiality: An LVN left a laptop open on a cart in the hallway with a resident’s PHI visible, including name, DOB, physician, code status, allergies, vital signs, weight, pain level, and medication information. In a separate incident, a CNA provided incontinent care with the window blinds open to the parking lot, leaving a resident’s perineal area and later breasts exposed while the resident had severe cognitive impairment and bowel/bladder incontinence.
Failure to Report Significant Weight Loss to Dietician: A resident with malnutrition and severe cognitive impairment had a documented weight drop from 140 lbs. to 122 lbs. in one week, exceeding the care plan’s threshold for significant weight loss. The DON did not notify the Dietitian when the loss was identified, and the consulting Dietitian stated she was not made aware and could not review the resident’s weight or adjust tube feeding if needed.
A resident with dysphagia and severe cognitive impairment had a g-tube and was ordered to have tube placement checked before meds and to receive 60 ml water flushes before and after administration. An LVN was observed giving crushed medication via the g-tube without verifying placement and used only 10 cc before and 20 cc after instead of the ordered amount. The LVN acknowledged the missed placement check and the reduced flush volume, and the DON and ADON confirmed the order should have been followed.
A resident was discharged to another facility without a completed discharge summary, as required by facility policy. While some documentation such as the face sheet and medication orders was provided, essential elements like the reason for discharge, medication reconciliation, and a final summary of the resident's status were missing. Staff interviews revealed inconsistent practices and uncertainty about discharge documentation responsibilities.
A resident with severe cognitive impairment eloped from a facility twice due to inadequate supervision and environmental hazards. Despite being in a secure unit, the resident broke a window and left the facility, being found by police hours later. On a second occasion, the resident scaled a fence after breaking another window. Staff were aware of the resident's elopement risk but failed to prevent these incidents.
The facility failed to maintain an adequate emergency water supply, leaving 68 residents at risk. Observations revealed no emergency water on site, and interviews with the Dietary Manager and Administrator showed a lack of awareness and responsibility for water storage. The Chief Nursing Officer confirmed the need for a three-day supply, which was not met, as the facility lacked the required 519 gallons of water for residents and employees.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as stained ceiling tiles, a precarious HVAC vent, inadequate clean linens, and a broken room door. These deficiencies affected residents' comfort and safety, with staff and management aware of the issues but unable to resolve them due to various constraints.
The facility failed to conduct EMR/NAR checks for a CNA prior to employment, as required by their Abuse Prevention Program. This oversight was discovered during a review of employment registry screenings, revealing that the HR Manager did not complete the necessary checks before the CNA's hire date. The Administrator confirmed the checks were not monitored, potentially placing residents at risk.
Three residents in an LTC facility did not receive scheduled showers, impacting their hygiene and dignity. A resident with quadriplegia was not bathed due to a lack of clean linens, while another with total paralysis had stained linens and unkempt hair. A third resident refused bed baths when clean linens were unavailable. Staff interviews revealed documentation and communication issues regarding shower refusals.
The facility failed to provide organized activities for residents in a secure unit, as observed over several days. Despite a scheduled activities calendar, no activities were conducted, and residents were left with minimal engagement. Staff interviews confirmed the absence of activities, and the Activity Director cited challenges in managing activities on and off the unit.
The facility failed to verify the certification status of two CNAs, allowing them to provide care without current certifications. The HR Manager did not complete the required EMR/NAR checks upon hire or annually, leading to expired certifications for CNA D and CNA E. Interviews revealed a lack of oversight and awareness of certification requirements, potentially risking resident safety.
A resident with chest pain did not receive her prescribed Ranolazine 1000 mg ER on multiple occasions due to a failure in the facility's pharmaceutical services. The medication aide ordered the medication twice, but it was not delivered, and the issue was not communicated to management in a timely manner. The facility's policy for ordering medication was not followed, leading to missed doses and a breakdown in communication among staff.
The facility failed to maintain kitchen sanitation standards, with dust and fuzz on air vents and grease buildup on the stove backsplash. Staff interviews revealed confusion over cleaning responsibilities, with the stove last cleaned a month ago and vents not cleaned for three months, contrary to the facility's sanitation policy and the Federal Food Code 2022.
The facility failed to maintain essential laundry equipment, resulting in a backlog of laundry and unclean linens for residents. A resident reported having stained sheets for six days and a lack of clean towels for showering. The facility operated with only one residential washing machine, as the commercial machine was broken. The Administrator acknowledged the issue and had requested a new machine from corporate.
The facility failed to provide privacy curtains for several resident rooms, compromising visual privacy. Observations showed missing curtains and window blind slats in multiple rooms. The HR Manager acknowledged responsibility but noted the floor tech responsible for curtains had quit. The Administrator confirmed no specific policy on privacy curtains, but they were covered under Resident Dignity policies.
The facility failed to provide adequate training on dementia and ANE for several CNAs and LVNs, as required by policy. Training transcripts lacked documentation of completed trainings, and there was no monitoring system to ensure compliance. The HR Manager and DON acknowledged the absence of a system to track training completion, which could lead to potential harm due to untrained staff.
A facility failed to ensure a resident was free from physical restraints unless needed for medical treatment. The resident, with severe cognitive impairment, had half bedrails in place without a care plan, safety assessment, or consent. Staff interviews revealed the bedrails were not used for mobility, contrary to the physician's order. The DON was unaware of the bedrail type, and the facility's policy on side rails was not followed.
A resident with severe cognitive impairment and multiple health conditions was sent to the hospital, yet her EMR inaccurately showed vital signs and medication refusals documented by LVNs. One LVN was not present, and the other admitted to documenting without verifying the resident's presence. The DON confirmed the resident had passed away at the hospital, highlighting a failure in maintaining accurate records.
A resident was issued an immediate discharge from a facility due to non-compliance with the smoking policy, but the facility failed to provide the required written notification to the resident and the Ombudsman. The resident, who had intact cognition and multiple medical conditions, was sent to a hospital for low sodium and was ready for discharge shortly after. However, the facility refused to readmit the resident, leaving them without a place to go and without proper discharge planning.
A resident with a history of elopement risk managed to leave a secured unit in an LTC facility due to a malfunctioning door alarm. The resident exited through a back door that did not sound an alarm, allowing him to leave unnoticed initially. Staff later found and returned the resident safely, but the incident revealed a significant lapse in safety measures.
Two incidents at the facility resulted in violations of resident rights and dignity. In the first case, a staff member recorded a resident with his cell phone while the resident was agitated, violating privacy policies. The resident had cognitive impairments and a history of behavioral issues. In the second case, a CNA removed a resident's cell phone to prevent him from calling 911 during a care episode, which was against the resident's rights. The resident had multiple sclerosis and cognitive deficits. Both incidents reflect a failure to respect residents' rights to dignity and communication.
The facility failed to serve pureed bread to residents on a pureed diet during a lunch meal. A dietary staff member forgot to prepare the bread, and the DM did not ensure all meal components were served. This oversight affected residents requiring a pureed diet, including one with dementia and malnutrition, as the facility did not follow its policy to meet residents' nutritional needs.
The facility failed to maintain an effective pest control program, leading to the presence of bugs in a resident's room and a dining area. Multiple residents and staff reported frequent sightings of bugs, including cockroaches, throughout the facility. Despite regular visits from a pest control company, the issue persisted, as documented in maintenance logs.
The facility failed to ensure Cook C wore a beard restraint while preparing and serving food, as observed during a lunch meal service. Cook C, with facial hair, was seen using a blender and plating meals without a beard restraint, contrary to the facility's policy and the Federal Food Code. Interviews revealed a lack of awareness and availability of beard restraints in the kitchen.
A resident with moderate cognitive impairment and a history of Alzheimer's was not provided necessary grooming services, resulting in unwanted facial hair. Despite the resident's desire for hair removal, staff did not offer or attempt to shave her chin, and there was no documentation of care refusal. Interviews with facility staff revealed a lack of awareness and action regarding the resident's grooming needs, contrary to the facility's policy requiring daily grooming.
The facility did not update the daily nurse staffing information on one occasion, as required by policy. Observations showed that the staffing information was not updated for the current day, and interviews revealed that the DON, responsible for the update, did not return to the facility. The ADON acknowledged the oversight, and the Administrator confirmed the requirement for daily updates.
A resident with schizoaffective disorder and other health issues was not re-admitted to the facility after being transferred to a behavioral health hospital. Despite the discharge assessment indicating a return was anticipated, the facility did not complete necessary paperwork or communicate effectively with the hospital. The DON and Administrator cited safety concerns and property damage as reasons for not allowing the resident to return.
A resident's urinary catheter was found on the floor, contrary to infection control protocols. The resident, with a complex medical history, was unaware of the catheter's position. The LVN repositioned the catheter after surveyor prompting. The DON and Administrator confirmed the expectation for proper catheter positioning, aligning with facility policy.
A resident in a LTC facility was unable to use a non-functional call light system, impacting her ability to request assistance. Despite being cognitively intact and requiring a wheelchair, she had to self-propel to the nurse's station for help. The LVN was unaware of the issue, and the maintenance log showed no record of the malfunction. The Corporate Maintenance Director and Administrator both emphasized the importance of a functioning call light system, which was not adhered to as per facility policy.
The facility failed to provide adequate supervision and assistive devices to prevent accidents for three residents. One resident experienced a fall resulting in a sacrum fracture, another eloped from a secured unit due to a malfunctioning door, and a third sustained burns from accessing a microwave in an unlocked staff break room.
Unclean Resident Rooms and Shower Room
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for seven resident rooms on the Sunflower Hall and for one shower room. During observation, the shower room tub had brownish and grayish stains near the drain hole and on the front panel. Multiple resident rooms were observed with unclean conditions, including dark stains in bathroom corners and behind toilets, white shredded tissue pieces near a wall, brownish stains on walls, built-up dirt in door frame and floor corners, grayish stains on room floors, dark stains near closets, a brownish substance near a wall, and a privacy curtain with reddish and black stains all over it. Housekeeping staff and the Housekeeping Supervisor stated that housekeeping was responsible for cleaning the entire resident rooms, including bathrooms, and the entire shower room. One housekeeper stated she was not assigned to the Sunflower section but would be assigned there moving forward, and she stated not cleaning areas thoroughly could cause residents to get an infection. The Housekeeping Supervisor stated the rooms and shower rooms were supposed to be cleaned thoroughly and that if they were not, it could impact resident health. The Administrator was informed of the concerns and stated the rooms needed to be thoroughly cleaned because they should be a homelike environment for residents. The facility policy stated residents have the right to a safe, clean, comfortable, and homelike environment.
Care Plans Missing Key Interventions for Catheter Care, Fall Safety, and Smoking
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents whose assessments and orders identified specific needs. For Resident #1, who was admitted with neuromuscular dysfunction of the bladder and had severe cognitive impairment with an indwelling catheter, the physician ordered Foley/Suprapubic catheter care every shift and as needed. On review of the comprehensive care plan, no catheter care plan was present, even though the resident had returned to the facility with a catheter and a catheter bag was observed hanging on the bed frame during the survey. For Resident #7, who had muscle wasting, severe cognitive impairment, and an active diagnosis of inflammation and infection of the bones, the comprehensive care plan identified the resident as a fall risk. However, the care plan did not include interventions for the bed to be in the lowest position or for a fall mat to be placed alongside the bed. During observation, the resident was lying in bed with the bed in the lowest position and a fall mat beside the bed, but those interventions were not reflected in the care plan at the time of review. For Resident #34, who had mental and behavior disorders and severe cognitive impairment with dementia, the comprehensive care plan did not reflect that the resident was a smoker. The smoking assessment indicated the resident used tobacco products, and staff later confirmed the resident was still smoking and had been observed smoking outside. The facility policy stated that comprehensive care plans must include all services identified in the comprehensive assessment, but the reviewed care plans for these residents did not include the identified catheter care, fall interventions, or smoking needs.
Missing Orders, Inaccurate Smoking Assessments, and Hazardous Item Left in Room
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards for residents identified as fall risks and smokers, and failed to keep a hazardous household chemical out of a resident’s room. Resident #7 had a diagnosis of muscle wasting, a BIMS score of 6, and was identified in the care plan as a fall risk with a scoop mattress intervention. He was observed lying in bed on a scoop mattress, but the physician order record did not include an order for the scoop mattress. Staff stated the mattress was used to support him because he often tried to get out of bed without help, and that physician orders were needed so the mattress would not be considered a restraint. Resident #66 had diagnoses of muscle weakness and lack of coordination, a BIMS score of 99, and was also identified as a fall risk with a scoop mattress intervention in the care plan. He was observed lying in bed on a scoop mattress, but his physician order record also did not include an order for the mattress. The ADON and DON stated both residents were fall risks and that nurses were responsible for obtaining physician orders for the scoop mattress, but they were not aware the orders were missing. Resident #34’s record showed a smoking assessment dated 12/12/25 indicating tobacco use, but the comprehensive care plan did not reflect that the resident was a smoker. Resident #41’s care plan stated he dipped snuff and required no supervision, while his smoking assessment dated 08/22/25 stated he did not use tobacco products. During observation, he was seen with a can of chewing tobacco on his nightstand and stated he chewed tobacco and currently had chewing tobacco in his mouth. Staff stated the resident should have had quarterly smoking assessments completed. Resident #54 was observed with a container of odor neutralizer on top of her mini refrigerator in plain view. The container had a warning that it may cause sensitivity or irritation to skin, eyes, and/or lungs and to keep it out of the reach of children. Staff stated the deodorizer should not have been left in the room because it contained chemicals and could be hazardous to residents.
Medications Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in locked compartments and were not left accessible inside resident rooms for four residents. During observations, a roll-on pain relieving gel was found on the overbed table in Resident #22’s room, where it was in plain view and accessible. Resident #22 had diagnoses including Alzheimer’s disease, bipolar disorder, and right leg pain, had a BIMS score of 12, and had no assessment for self-administration of medications and no physician order for the topical roll-on analgesic. A tube of zinc oxide was observed on top of Resident #20’s overbed table beside a food tray. Resident #20 had dementia and depression, a BIMS score of 6, and was incontinent of bowel and bladder. The resident’s care plan included barrier cream as needed, but the clinical assessment notes showed no assessment for self-administration of medications. A tube of zinc oxide was also observed on top of Resident #39’s drawer and visible from the hallway. Resident #39 had dementia, a BIMS score of 10, was incontinent of bowel and bladder, and also had no assessment for self-administration of medications. Two sachets of barrier cream were observed on Resident #67’s side table, including one opened sachet. Resident #67 had cognitive impairment and kidney disease, a BIMS score of 15, and was incontinent of bowel and bladder. The resident’s care plan included barrier cream for incontinence-related skin risk, but the clinical assessment notes showed no assessment for self-administration of medications. Staff interviews confirmed that the creams and topical medications should not have been left inside resident rooms unless the resident had been assessed as safe to self-administer, and the facility policy stated that medications were to be stored in locked compartments with access limited to authorized personnel.
Kitchen Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen, which was the only kitchen reviewed for food and nutrition services. During observation, the Dietary Manager was in the kitchen near a pot of food being cooked and was not wearing a head cover. A vendor was also in the kitchen making repairs near the food being cooked and was not wearing a beard cover; the vendor’s beard was at least half an inch long. The kitchen observation also identified an ice machine with reddish stains along the inside panel wall. In the freezer, two large bags of sausages, one large bag of taquitos, and one large bag of cookie dough were not dated with the month, day, and year they were stored upon receipt from the vendor. The deep fryer in the kitchen area had light brownish substances floating all over the top of the cooking oil. During interview, the Dietary Manager stated she had removed her hairnet when she briefly left the kitchen and forgot to put it back on while preparing lunch. She stated she had the vendor place a hairnet on but forgot to have him place a beard covering on. She also stated she cleaned the ice machine weekly, believed the year did not need to be included on stored food because staff used first in, first out, and did not think the deep fryer needed cleaning because it had not been used for a long period of time and was inoperable. The Administrator stated she expected the kitchen to comply with policy and that the concerns observed could result in food contamination.
Infection Control Failures During Resident Care and Blood Sugar Monitoring
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents reviewed for infection control. During observation, interview, and record review, staff were observed not following hand hygiene, glove-changing, and PPE practices during resident care and treatment activities. For Resident #19, the record showed the resident had severe cognitive impairment with a BIMS score of 0 and bowel and bladder incontinence. The care plan directed staff to clean the resident’s perineal area after each episode of incontinence. During an observation of incontinent care, CNA C washed her hands and put on gloves, then completed care. After she noticed the resident’s left inner upper leg was still soiled, she used wipes to clean the area and then continued fixing the brief without changing her gloves. During interview, CNA C stated she should have changed her gloves when she wiped the resident’s legs to prevent UTI. For Resident #23, the record showed the resident had bowel and bladder incontinence, a sacral wound, and enhanced barrier precautions were ordered for wound-related high-contact care activities. During observation of incontinent care, CNA D entered the room, put on gloves, but did not wash her hands before gloving and did not wear a gown despite the EBP sign outside the room stating a gown was required. She removed her gloves, pulled another pair from her pocket, and did not sanitize her hands when changing gloves. She also did not change gloves after cleaning the resident’s bottom before touching the new brief. During interview, CNA D stated she forgot the gown, said hands should be washed before and after incontinent care, said gloves should be changed after cleaning the resident’s bottom, and said gloves should not be placed in pockets because the pockets were not always clean. For Resident #86, the record showed the resident had diabetes mellitus and was receiving insulin. During observation, LVN A prepared to check the resident’s blood sugar, put on gloves, and proceeded with the fingerstick without sanitizing his hands first. During interview, LVN A stated he should have sanitized his hands before checking the blood sugar. The ADON and DON both stated that hand hygiene, glove changes, and gown use for residents on enhanced barrier precautions were expected to prevent cross contamination and spread of infection.
Call Lights Not Kept Within Reach of Two Residents
Penalty
Summary
The facility failed to ensure the call light system was accessible to two residents, Resident #34 and Resident #60, both of whom were identified in care plans as needing their call lights within reach. Resident #34 was a female with abnormalities of gait, physical debility, and severe cognitive impairment with a BIMS score of 04. Her care plan identified her as at risk for falls and directed that her call light be within reach. During observation, her call light was found on the floor and tucked behind her side table, and she stated staff had forgotten to clip it again and that she had been looking for it since morning. Resident #60 was a cognitively intact male with muscle weakness, visual loss, and chronic pain. His care plan also identified him as at risk for falls and directed that his call light be in reach. During observation, his call light was found on the floor under his roommate’s bed, and he stated he had been looking for it since the day before and could not find it at the side of his bed. The LVN later located the call light under the roommate’s bed and clipped it to the side of the bed. Staff interviews confirmed that call lights were intended to allow residents to summon assistance and that they were supposed to remain accessible at all times. The LVN stated the call lights should have been with the residents before staff left the room and that the residents might be unable to get up to retrieve them if in distress. The CNA said she had completed morning rounds but did not notice the call lights were not with the residents. The ADON, DON, and Administrator all stated call lights should be within reach of residents at all times and that staff were responsible for ensuring they remained accessible.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain confidentiality of a resident’s medical information when an LVN left a laptop open on a cart in the hallway with the screen facing outward. Resident #7 had diagnoses of hypotension and hypertension, a severe cognitive impairment with a BIMS score of 06, and an order for Midodrine via PEG tube for low blood pressure. During observation, the laptop displayed the resident’s name, date of birth, physician name, location, code status, allergies, special instructions, latest vital signs, latest weight, latest pain level, and medication information while the LVN walked away from the cart and left the screen exposed. The LVN later stated he had gone to get something and acknowledged that leaving the resident’s information exposed was a HIPAA violation. He said the information should have been secure and confidential and that he should have minimized or locked the screen before leaving the cart unattended. The ADON and DON also stated that the computer should have been closed or locked to prevent exposure of resident information. The facility also failed to maintain privacy during incontinent care for Resident #19, who had severe cognitive impairment with a BIMS score of 00 and bowel and bladder incontinence. During observation, CNA C pulled the privacy curtain but did not close the window blinds even though the resident’s bed was parallel to a window overlooking the parking lot. The resident’s perineal area remained exposed during care, and after care the CNA removed the resident’s gown, exposing her breasts, while the blinds were still open and there was no curtain on the window. CNA C stated she thought the blinds were not working, then checked and found they did work, and said she should have closed them to provide privacy from outside the facility.
Failure to Report Significant Weight Loss to Dietician
Penalty
Summary
The facility failed to ensure Resident #7 maintained acceptable nutritional status and electrolyte balance when it did not notify the Dietician of a significant weight loss. Resident #7 was a male with a diagnosis of malnutrition and severe cognitive impairment, with an initial MDS reflecting a BIMS score of 6. The comprehensive care plan directed staff to monitor and report signs of malnutrition and significant weight loss, including 3 lbs. in 1 week, >5% in 1 month, >7.5% in 3 months, and >10% in 6 months. The resident’s weight was documented as 140 lbs. on 03/12/26 and 122 lbs. on 03/19/26, which was over a 12% decrease in one week. During the survey, the DON stated the weekly weight had been charted on paper and that she did not think the original weight was recorded correctly, but she had not reported the suspected weight loss to the Dietician when it was observed. The DON stated she was waiting to notify the Dietician when she visited the facility. The consulting Dietitian stated she had not been made aware of the reduction in weight and that the facility should have notified her so she could review the resident’s weight and make modifications to the tube feeding if needed. The facility policy on Weight Monitoring stated that the physician should be informed of significant weight loss and the Registered Dietitian or Dietary Manager should be consulted to assist with interventions.
G-tube Placement Not Verified and Ordered Flush Volumes Not Followed
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one resident with a g-tube. Resident #7 was a male admitted with dysphagia, had severe cognitive impairment with a BIMS score of 06, and was documented on the MDS as having a feeding tube. His care plan required tube feeding and included monitoring for nausea, vomiting, bloating, and discomfort during or after feeding. On 04/08/2026, LVN A was observed preparing to administer medication through the resident’s g-tube. He crushed the medication, brought it to the room, disconnected the g-tube from the formula, attached a syringe, checked residual, and flushed the tube with 20 cc of water before giving the medication and 10 cc after. He did not check g-tube placement before flushing or administering the medication, even though the physician order required checking enteral tube placement prior to giving meds or bolus feedings by air auscultation and aspirating contents. The physician order also required flushing the enteral tube with 60 ml of water before and after medications or bolus feedings, but LVN A used only 10 cc before and 20 cc after. During interview, he stated he forgot to check placement and acknowledged the ordered flush amount was not followed. The ADON and DON both stated that placement should be checked before medication administration and that the ordered flush amount should be given. The facility policy stated that tube placement would be verified before beginning a feeding and before administering medications.
Failure to Complete Required Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to complete a required discharge summary for a resident who was discharged to another healthcare facility. Record review showed that while the resident's face sheet, medication orders, and belongings were provided at discharge, there was no comprehensive discharge summary in the clinical records. The available documentation, including the Summary Episode Note, did not address key elements such as the reason for discharge, date of discharge, reconciled medications sent to the new facility, personal belongings disposition, or physician signature. Additionally, the resident's care plan did not address discharge goals. Interviews with facility staff revealed inconsistent understanding and implementation of discharge documentation procedures. The nurse responsible for the discharge documented the transfer in progress notes and provided some information to the receiving facility, but did not complete a full discharge summary as required by facility policy. The DON and Administrator both indicated uncertainty or changes in policy regarding who was responsible for completing the discharge summary, and the process was not followed for this resident. The facility's own policy required a comprehensive discharge summary to be completed by the interdisciplinary team, but this was not done.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and provide adequate supervision to prevent elopement for a resident with severe cognitive impairment. The resident, who had a history of elopement and was diagnosed with dementia, managed to leave the facility on two separate occasions. On the first occasion, the resident broke a window in his room and was found by the police after being missing for several hours. The facility's secure unit was not adequately monitored, and the resident's risk of elopement was not sufficiently mitigated. The resident was placed in a secure unit due to his risk of wandering and elopement, yet the interventions in place were insufficient. Despite being on enhanced supervision, the resident was able to break a window and exit the facility. Staff interviews revealed that the resident was known to pack his belongings and stand by exit doors, indicating a desire to leave, but he was usually redirected back to his room. However, on the day of the incident, the staff failed to prevent his elopement. On a subsequent occasion, the resident again managed to elope by breaking a window and scaling a newly constructed fence. The fence was improperly constructed with rails on the inside, facilitating the resident's escape. Staff witnessed the resident climbing the fence but were unable to reach him in time. The facility's failure to provide adequate supervision and secure the environment placed the resident at risk of harm and serious injury.
Inadequate Emergency Water Supply Puts Residents at Risk
Penalty
Summary
The facility failed to ensure an adequate emergency water supply was available, placing 68 residents at risk. During an observation, it was found that the facility had no emergency water on hand. Interviews with the Dietary Manager and the Administrator revealed a lack of awareness and responsibility regarding the storage and management of emergency water supplies. The Dietary Manager admitted to never ordering or being informed about emergency water storage, while the Administrator acknowledged the absence of a policy and the need for corporate guidance. The Chief Nursing Officer confirmed the necessity of having at least one gallon of water per resident for three days, which was not met. The facility's policies indicated a requirement for a three-day supply of water, but this was not adhered to. The record review showed discrepancies in the understanding and implementation of emergency water requirements, with the facility lacking the necessary 519 gallons of water for residents and employees. This oversight could lead to dehydration and other health complications for residents.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, ceiling tiles above a resident's bed were stained and had not been replaced for over a month, despite the resident notifying the nursing staff. Additionally, a ceiling HVAC vent in another resident's room was found to be hanging precariously due to a missing screw, posing a potential safety hazard. The facility also failed to provide adequate clean linens for residents, as observed in the case of a resident whose sheets had not been changed for approximately six days due to a shortage of clean linen. The laundry facilities were found to be lacking in clean linens, and the laundry supervisor acknowledged the shortage, attributing it to staff discarding dirty linens and the facility having only one functioning residential washing machine. The administrator was aware of the linen shortage but had not been able to secure a commercial washing machine due to budget constraints. Furthermore, the facility did not ensure that room doors were in proper working condition, as seen in the case of a resident whose door did not latch and remained open unless blocked by a wheelchair. This issue had persisted for a couple of months, and although the maintenance director was aware of the problem, it had not been addressed. The facility's policy on providing a homelike environment was not adhered to, as residents were not provided with a clean, sanitary, and orderly environment, nor with clean bed and bath linens in good condition.
Failure to Conduct EMR/NAR Checks for CNA Prior to Employment
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified during a review of the employment registry screenings for one of the eight employees, specifically CNA D. The facility did not ensure that a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care. This oversight could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The HR Manager, who began working at the facility in March 2024, acknowledged that no EMR/NAR checks were completed for CNA D before her hire date of July 7, 2023, nor was an annual EMR/NAR check conducted. The HR Manager stated that it was her responsibility to complete these checks both upon hire and annually. The Administrator confirmed that EMR/NAR checks were supposed to be completed by the HR Manager and that it was his responsibility to monitor their completion. The facility's current, undated Abuse Prevention Program outlines the requirement for conducting employee background checks to prevent employing individuals with a history of abuse, neglect, exploitation, or misappropriation of property.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, three residents, identified as Residents #29, #48, and #57, did not receive showers as scheduled. This deficiency was observed through record reviews, interviews, and direct observations, which revealed that these residents were not provided with adequate bathing services, leading to poor hygiene and potential risks to their health and dignity. Resident #29, a female with quadriplegia and other significant medical conditions, was dependent on staff for bathing. Her care plan did not address bathing or showering, and records showed she did not receive showers or bed baths during a specified period, with no documented refusals. Interviews revealed that she was told by staff that there were no clean linens or towels available, and she expressed feelings of diminished self-esteem due to the lack of personal care. Resident #48, a male with total paralysis due to multiple sclerosis, was also dependent on staff for ADLs. His care plan was not individualized, and he had a pressure ulcer. Observations noted that his bed linens were stained, and he had not been bathed recently, as confirmed by his statements. Similarly, Resident #57, a male with multiple health issues, required substantial assistance with bathing. He refused bed baths when clean linens were unavailable, citing the futility of washing only to return to a dirty bed. Interviews with staff, including CNAs, LVNs, and the DON, highlighted inconsistencies in documentation and communication regarding shower refusals and the importance of maintaining hygiene for infection control and resident dignity.
Lack of Activities in Secure Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of residents in a secure unit. Observations over several days revealed that no organized activities were conducted as per the facility's activities calendar. On multiple occasions, residents were seen in the dining room with the TV on, but no structured activities were taking place. Staff interviews confirmed that activities listed on the calendar were not being executed, and the Activity Director admitted to difficulties in managing activities both on and off the unit. The facility's policy on activity programs states that activities should be available daily and tailored to individual resident needs. However, the Activity Director acknowledged that none of the scheduled activities were conducted during the observed days, and only minimal engagement, such as painting nails, was attempted. The Administrator was unaware of the complete lack of activities and recognized the importance of activities in preventing resident boredom and potential behavioral issues.
Failure to Verify CNA Certification Status
Penalty
Summary
The facility failed to ensure that two certified nurse aides (CNAs), identified as CNA D and CNA E, had current nurse aide certifications while employed and actively providing care to residents. The facility did not complete the required EMR/NAR checks upon hire or annually for these CNAs. CNA D's personnel file showed no evidence of a completed EMR/NAR check, and CNA E's certification had expired without renewal. The HR Manager, who was responsible for conducting these checks, was unaware of the requirement to update both CNA and MA certifications annually until informed by regional management. The HR Manager had instructed CNA D to renew her certification, but it was not done, and CNA E was under the impression that renewing her MA certification would automatically renew her CNA certification. Interviews with the HR Manager, Director of Nursing (DON), and the Administrator revealed a lack of monitoring and oversight in ensuring that certifications were current. The HR Manager acknowledged her responsibility to conduct annual EMR/ENR checks but stated that it was also the staff's responsibility to keep their certifications current. The DON and Administrator confirmed that the HR Manager was responsible for these checks and that the failure to maintain active certifications could lead to potential harm to residents, including falls, fractures, and incorrect procedures. The facility's policy required all nursing staff to meet specific competency requirements as defined by state law, which was not adhered to in this case.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of Ranolazine 1000 mg ER for chest pain. The resident, a female with a diagnosis of chest pain and moderate cognition, did not receive her prescribed medication on several occasions. The medication was not administered on the evenings of February 3rd and 4th, and the mornings of February 4th and 5th, as documented in the Medication Administration Record (MAR). The medication aide (MA) responsible for administering the medication was aware of the shortage and had ordered the medication from the pharmacy twice, but it was not delivered. The MA failed to notify management about the missing medication, although she informed the nurse. The charge nurse was not made aware of the issue until February 5th, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were also not informed until later. The facility's policy required medication to be ordered when seven tablets remained, but this was not adhered to, leading to the missed doses. Interviews with facility staff, including the MA, charge nurse, ADON, DON, and the pharmacist consultant, revealed a breakdown in communication and procedure adherence. The pharmacist consultant noted that the facility should have followed up with the pharmacy within 24 hours of ordering and notified the doctor for a substitute medication. The physician assistant was not aware of the issue until February 5th and instructed the facility to hold the medication until it was available. The facility's failure to ensure timely medication refills and communication with the pharmacy and physician led to the resident missing critical doses of her medication.
Deficiency in Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain kitchen sanitation standards, as observed during a survey. Specifically, three air conditioning vents over the food preparation area and two vents by the dishwasher were found to have accumulated fuzz and dust. Additionally, the stove backsplash was observed to have a buildup of grease. These conditions were noted on two consecutive days, with food being prepared in the kitchen during the second observation. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities. A staff member was unsure who was responsible for cleaning the stove backsplash and could not recall the last cleaning. The Dietary Manager indicated that kitchen staff, particularly cooks, were responsible for cleaning the stove, which was last cleaned about a month ago. The Maintenance Supervisor was uncertain about who should clean the air vents, which had not been cleaned for approximately three months. The facility's sanitation policy and the Federal Food Code 2022 require that food service areas and equipment be maintained in a clean and sanitary manner, free from dust, grease, and other contaminants.
Failure to Maintain Essential Laundry Equipment
Penalty
Summary
The facility failed to maintain essential equipment, specifically a laundry washing machine, in safe operating condition. This deficiency was observed when Resident #37 was found with large brown stains on his bed sheets, which had been unchanged for about six days. The resident also reported being unable to shower due to a lack of clean towels. The facility's laundry area was found to have only one operational residential washing machine, as the commercial washing machine was broken with parts removed and placed on top of it. Interviews with the Laundry Aide and Laundry Supervisor revealed that the facility had been operating with only one residential washing machine for about a month, leading to a backlog of laundry. The Administrator acknowledged the insufficiency of one residential washing machine for the facility's needs and stated that he had requested a new machine from corporate multiple times. The Administrator also mentioned that the facility had sent laundry out for cleaning on a few occasions. The facility's Quality of Life-Homelike Environment policy emphasizes providing residents with a clean and comfortable environment, which was not upheld due to the equipment failure.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure that each bed had ceiling-suspended curtains to provide total visual privacy for residents in several rooms. Observations revealed that multiple rooms lacked privacy curtains at the end of the beds, and some rooms had no privacy curtains at all. Additionally, there were missing slats in the window blinds in one of the rooms. This lack of privacy curtains was noted in rooms #110, #117, #118, #120, #122, #127, and #144, which could compromise the residents' privacy. Interviews conducted with the HR Manager and the Administrator highlighted that the responsibility for changing out the curtains fell to a floor technician who had recently quit and had not been replaced. The HR Manager acknowledged her ultimate responsibility for ensuring privacy curtains were in place. The Administrator confirmed that there was no specific policy addressing privacy curtains, but they were considered under the broader policy of Resident Dignity. The facility's undated policy on Quality of Life-Dignity emphasized respecting residents' private space and property, including knocking before entering rooms and not handling personal belongings without permission.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for eight out of eleven staff members reviewed for training. Specifically, the facility did not provide training on dementia and abuse, neglect, and exploitation (ANE) for CNAs A, B, C, D, E, and LVNs G and H. The training transcripts for these staff members did not indicate when the last ANE or dementia training had been completed, which is a requirement according to the facility's policy. Interviews with the HR Manager and the Director of Nursing (DON) revealed that there was no monitoring system in place to ensure that required trainings were completed and documented in the staff's employee files. The HR Manager stated that all required trainings were to be completed every two years and that staff were directed to complete their trainings online, with completion certificates to be submitted to the DON. However, the DON admitted that some in-service trainings were conducted in person but could not be located during the survey. The Administrator also confirmed the lack of a monitoring system to ensure trainings were completed, acknowledging the potential for harm when staff are not properly trained. The facility's policy requires nursing staff to participate in a competency-based staff development and training program, which includes preventing abuse, neglect, and exploitation, as well as dementia management.
Failure to Properly Assess and Care Plan for Bedrail Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment. Specifically, the facility did not care plan for the use of half bedrails for a resident who was at risk for falls and had severe cognitive impairment. The resident's care plan did not address the use of bedrails, and there was no assessment for bedrail safety or consent for their use from the resident's responsible party. The resident had a physician order for bedrails for mobility, but observations indicated that the resident did not use the bedrails for mobility and was unable to follow requests to reposition herself using them. Interviews with facility staff revealed that the resident did not use the bedrails for mobility and would only grab onto them when being turned for incontinent care. The Director of Nursing (DON) was unaware that the resident's bedrails were half rails instead of mobility bars and stated that bedrails should only be used for mobility, not to keep the resident in bed. The facility's policy on the proper use of side rails was not followed, as it requires an assessment for the use of side rails, consent from the resident or legal representative, and inclusion in the resident's care plan.
Inaccurate Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a deficiency in accordance with accepted professional standards. The resident, a female with severe cognitive impairment and multiple health conditions including congestive heart failure, diabetes, and chronic kidney disease, was sent to the hospital following a fall. Despite the resident's absence from the facility, her electronic medical records (EMR) inaccurately reflected vital signs and medication refusals, which were documented by two Licensed Vocational Nurses (LVNs). Interviews revealed that LVN B, who was not present on the day in question, had her password saved on the computer, allowing another nurse to document under her credentials. LVN A, who was working that day, admitted to documenting the resident's medication refusals and vitals without verifying the resident's presence in the facility. The Director of Nursing (DON) confirmed that the resident had passed away at the hospital earlier that day, making it impossible for the documented events to have occurred at the facility. The facility's documentation practices were called into question, as the DON and Assistant Director of Nursing (ADON) acknowledged that nurses may have been careless with password security and documentation accuracy. The facility's policy required that all services and changes in a resident's condition be accurately documented by licensed personnel, but this was not adhered to, resulting in the deficiency.
Failure to Notify Resident and Ombudsman of Immediate Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the Office of the State Long-Term Care Ombudsman of an immediate discharge, as required by regulations. The resident, who had a history of non-compliance with the facility's smoking policy, was issued a 30-day discharge notice due to this non-compliance. However, the facility later decided to issue an immediate discharge notice without providing the required written notification to the resident and the Ombudsman. The resident, who had intact cognition as indicated by a BIMS score of 15, was admitted to the facility with multiple diagnoses, including a fibroblastic disorder, Type II diabetes, muscle weakness, a personality disorder, and an acquired absence of the right leg below the knee. Despite the resident's refusal to adhere to the smoking policy, the facility's documentation did not show that the resident or the Ombudsman received a written copy of the immediate discharge notice. Interviews with the DON and the Ombudsman revealed that the Ombudsman was not aware of the immediate discharge notice, and the resident was not provided with the necessary documentation. The resident was sent to a local hospital due to critical lab results for low sodium and was ready for discharge a few days later. However, the facility refused to readmit the resident, citing the 30-day discharge notice. This left the resident without a place to go, as the facility did not assist in finding alternative placement. The facility's failure to provide proper notification and assistance with discharge planning placed the resident at risk of not having access to advocacy services and discharge options.
Resident Elopement Due to Faulty Door Alarm
Penalty
Summary
The facility failed to ensure adequate supervision and functioning assistive devices to prevent accidents, specifically for a resident who eloped from a secured unit. The resident, who had a history of elopement risk and cognitive impairment, managed to exit the facility through a back door that was not properly secured. The door alarm did not sound, allowing the resident to leave the premises unnoticed initially. The resident, who had been admitted to the secured unit due to his risk of wandering and elopement, was able to leave the facility because the back door was not functioning correctly. Staff interviews revealed that the door alarm did not activate, and the door was found wide open. The resident was eventually found by staff and returned to the facility without injury, but the incident highlighted a significant lapse in the facility's safety measures. The deficiency was identified as past noncompliance, with the immediate jeopardy situation beginning and ending over a two-day period. The facility's failure to maintain a secure environment and provide adequate supervision placed the resident at risk of harm, severe injury, or even death. The incident underscored the importance of ensuring that all exit doors are properly secured and alarms are functioning to prevent similar occurrences.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, leading to a deficiency in the care provided to two residents. The first incident involved the Maintenance Director recording a resident with his personal cell phone while the resident was yelling and cursing at the staff. The resident, who had a history of stroke, hemiplegia, and traumatic brain injury, was cognitively impaired and used a wheelchair for mobility. The Maintenance Director claimed he recorded the incident to show management how the resident treated him, but he was unaware that recording residents was against policy. The Administrator confirmed that the Maintenance Director had been trained on managing residents with behaviors and acknowledged that recording the resident was a violation of the resident's rights. The second incident involved a CNA taking away a resident's cell phone when the resident attempted to call 911. This resident had multiple sclerosis, cognitive communication deficit, and muscle weakness, with a moderately impaired cognition. The resident had a history of refusing care and being verbally and physically aggressive. During an episode where the resident was being changed, he became upset and attempted to call 911, prompting the CNA to take his phone away. The CNA stated she was following the DON's orders, although the DON later denied instructing staff to remove the resident's phone. The phone was eventually returned to the resident, but the incident was recognized as a violation of the resident's rights. Both incidents highlight the facility's failure to uphold residents' rights to dignity, self-determination, and communication. The actions of the Maintenance Director and the CNA, whether intentional or due to misunderstanding, resulted in breaches of privacy and autonomy for the residents involved. The facility's policies on electronic devices and resident rights were not adhered to, leading to these deficiencies in care.
Failure to Serve Pureed Bread to Residents on Pureed Diet
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents requiring a pureed diet during the lunch meal on September 10, 2024. Specifically, pureed bread was not served to eight residents who required it, including a resident with non-Alzheimer's dementia and malnutrition. This oversight was identified through observation, interviews, and record reviews, which revealed that the dietary staff did not follow the menu that was supposed to meet the nutritional needs of the residents. The deficiency occurred because the dietary staff member responsible for preparing the pureed bread forgot to make it, and the Dietary Manager (DM) did not verify that all meal components were prepared and served. The DM acknowledged that the omission of meal components could lead to missing nutritional values in residents' diets. The facility's policy requires that menus meet the nutritional needs of residents, but this was not followed, resulting in a failure to provide the necessary dietary components to residents on a pureed diet.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of small brown bugs in one resident's room and a dining area. Observations and interviews revealed that multiple residents and staff members noticed bugs throughout the facility, including cockroaches and other insects. Resident #3 reported finding bugs in his room every night, which crawled into his shoes, while Resident #7 observed bugs daily and claimed that staff did not address the issue. On-site observations confirmed the presence of bugs in Resident #6's room and the Sunflower hallway. Interviews with staff, including CNAs, LVNs, and the Maintenance Director, indicated that bugs were frequently seen in various areas of the facility. Staff members reported these sightings to the maintenance department, which logged them in a maintenance book. The Maintenance Director acknowledged the pest issue and stated that a pest control company visited regularly. However, the problem persisted, as evidenced by the maintenance request logs that documented pest control requests and sightings over several months. The facility's policy required immediate communication of pest sightings to management and documentation in the maintenance work order binder.
Failure to Use Beard Restraints in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the actions of Cook C, who did not wear a beard restraint while in the food preparation area and during the lunch meal service. On the specified date, Cook C was seen with facial hair on his chin and was not wearing a beard restraint while using a blender to prepare pureed meat for lunch. Later, during the lunch meal service, Cook C was observed plating meals for residents without a beard restraint, which could potentially lead to food contamination. Interviews conducted with the Dietary Manager (DM) and Cook C revealed a lack of awareness and availability of beard restraints in the kitchen. The DM admitted to not having heard of beard restraints before and confirmed that none were available for staff with facial hair. The facility's policy on preventing foodborne illness requires the use of hair nets or caps and beard restraints to prevent hair from contacting exposed food. This policy aligns with the Federal Food Code 2022, which mandates the use of effective hair restraints where appropriate.
Failure to Provide Necessary Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services to a female resident with moderate cognitive impairment, as evidenced by the presence of unwanted facial hair. The resident, who had a history of Alzheimer's, myopathies, Type 2 diabetes with neuropathy, and other conditions, required assistance with activities of daily living (ADLs) such as personal hygiene. Despite the resident expressing a desire to have her facial hair removed, staff did not offer or attempt to shave her chin, and there was no documentation of any refusal of care by the resident. Interviews with facility staff, including a CNA, LVN, and the ADON, revealed a lack of awareness and action regarding the resident's grooming needs. The CNA, who had been caring for the resident for two weeks, did not notice the facial hair and had not attempted to shave it. The LVN and ADON were also unaware of the issue, and there was no documentation of grooming refusals in the resident's records. The facility's policy required residents to be groomed daily, but this was not adhered to in the case of this resident, leading to a deficiency in maintaining her dignity and self-esteem.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily, as required by their policy. On 08/29/24, observations at multiple times throughout the day revealed that the staffing information posted near the facility's entrance was dated 08/28/24, indicating that it had not been updated for the current day. This oversight was confirmed through interviews with the Assistant Director of Nursing (ADON) and the Administrator, who both acknowledged the lapse in updating the staffing information. The ADON stated that the Director of Nursing (DON) was responsible for updating the daily staffing post, but the DON had left the facility at the end of her shift on 08/28/24 and did not return the following day. The ADON admitted that she might have been responsible for updating the post in the absence of the DON but had not done so. The Administrator confirmed that the staffing posting should be updated daily and was unaware of why it was not updated for 08/29/24. The facility's policy requires that the number of nursing personnel responsible for direct care be posted within two hours of each shift's start, but this was not adhered to on the day in question.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization or therapeutic leave, violating the bed-hold policy. The resident, a male with schizoaffective disorder, heart failure, hyperlipidemia, mild cognitive impairment, and hypertension, was initially admitted to the secure unit of the facility. He was transferred to a behavioral health hospital following an incident where he expressed suicidal ideation and self-harm. Despite the discharge assessment indicating a return was anticipated, the facility did not re-admit him. The resident's care plan included interventions for behavioral problems, but there was no documentation of his transfer to the hospital or a discharge summary. Interviews with facility staff revealed that the resident exhibited unusual behaviors, such as pacing and attempting to intimidate others. After the incident, emergency services transferred him to the hospital, but the facility did not complete the necessary paperwork or communicate effectively with the behavioral health hospital regarding his return. The Director of Nursing (DON) and the Administrator both indicated that the resident would not be allowed to return due to safety concerns and property damage. The Administrator stated that residents are considered discharged once sent to a hospital, and no discharge documents were sent with the resident. The behavioral health hospital's Program Director confirmed that the facility did not provide the necessary documentation or communication, placing the resident at risk of an unsafe discharge.
Infection Control Deficiency: Urinary Catheter Positioning
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, as evidenced by the improper positioning of a urinary catheter for a resident. The resident, who was admitted to the facility from an acute care hospital, had a urinary catheter that was observed to be on the floor. This was noted during an observation and interview with the resident, who was unaware of the catheter's position and its significance in infection control. The resident's medical history included encephalopathy, heart disease, hypertension, cerebrovascular disease, hemiplegia following cerebral infarction, and dementia. The resident's nurse, LVN B, confirmed the catheter's position on the floor and repositioned it after being prompted by the surveyor. The Director of Nursing (DON) and the facility Administrator both acknowledged the expectation that urinary catheters should not touch the floor and should be frequently checked by nursing staff. The facility's policy on catheter care also specified that the catheter bag should be positioned below the bladder level and not touch the floor, indicating a lapse in adherence to established protocols.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that a functional call light system was available for a resident, which compromised the resident's ability to call for staff assistance. The resident, who was cognitively intact and required a wheelchair for mobility, reported that her call light had not been working for an unspecified period. This issue forced her to self-propel to the nurse's station for assistance, which she found inconvenient. The resident's care plan included the need to call for assistance when in pain, highlighting the importance of a functional call light system for her care. During the investigation, it was confirmed that the call light in the resident's room was not functioning, as it did not signal at the nurse's station. The Licensed Vocational Nurse (LVN) interviewed was unaware of the malfunction and could not provide a maintenance log for review. The Corporate Maintenance Director stated that he was not aware of the issue and emphasized the importance of a functioning call light system. The facility's Administrator acknowledged the deficiency and stated that staff should conduct daily rounds to check call light functionality. The facility's maintenance log showed no record of the call light issue, and the facility's policy required prompt reporting and repair of defective call lights.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for three residents. Resident #1, a male with severe cognitive impairment and multiple physical disabilities, experienced an unwitnessed fall resulting in a non-displaced sacrum ring fracture. The fall occurred when a CNA left the resident alone during incontinence care to retrieve more wipes, despite the resident's known impulsiveness and need for constant supervision during such activities. The CNA was later terminated for negligence, and the facility acknowledged that the CNA should have called for assistance instead of leaving the resident alone. Resident #2, a male with severe cognitive impairment and a history of elopement, managed to leave the facility's secured unit without triggering any alarms. The resident was found by a housekeeper outside the facility and brought back. The incident revealed that the back door of the secured unit was not functioning properly, as it did not lock or set off an alarm when the resident exited. The facility's maintenance logs showed that the door had been checked regularly, but the malfunction was not identified until after the elopement. Resident #3, a male with moderate cognitive impairment, sustained burns on his left foot's first and second toes after accessing a microwave in an unlocked staff break room. The resident's care plan noted a risk for skin breakdown, and the burns were treated with various dressings over time. The incident highlighted the facility's failure to secure areas containing potential hazards, such as the staff break room, to prevent residents from accessing dangerous equipment like microwaves.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Arlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage At Turner Park Health & Rehab | 2.7 mi | ★★★★★ | 1 | 0 |
| Avir At Arlington | 4 mi | ★★★★★ | 13 | 3 |
| Viridian Wellness & Rehabilitation | 4.2 mi | — | 25 | 0 |
| Purehealth Transitional Care At Thr Arlington | 5.6 mi | ★★★★★ | 0 | 0 |
| Arbrook Plaza | 5.9 mi | ★★★★★ | 12 | 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 August 2026) and official state health department websites.