Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Town Hall Estates Arlington, Inc. during CMS and state inspections, most recent first.
A resident with dementia and schizophrenia, assessed as a moderate risk for wandering, was left unsupervised outside after the receptionist left, allowing her to leave the facility grounds unnoticed. Staff did not previously identify her as an elopement risk, and she was found walking down the street before being safely returned by staff. The lapse in supervision led to the deficiency.
A resident did not receive appropriate care for existing pressure ulcers, and measures to prevent new ulcers were not consistently implemented, resulting in a deficiency related to pressure ulcer management.
A resident with moderate cognitive impairment and multiple diagnoses began receiving antipsychotic medications before the responsible party signed consent forms, with no documentation of verbal consent prior to administration. Staff interviews confirmed that consents should be obtained before medication is given, but the process was not followed, and the facility lacked a specific policy on consents.
A resident with multiple chronic conditions and severe cognitive impairment was not assisted in obtaining dentures, despite being edentulous and expressing a desire for them. The Social Services Director did not follow up on a dental referral for over five weeks, contrary to facility policy requiring timely vendor contact. The resident remained without dentures and continued on a mechanical soft diet.
Surveyors found unsanitary conditions in the kitchen, including a long-standing dark substance on the walk-in cooler floor that had not been cleaned, and improper food storage practices such as previously thawed and re-frozen ground beef in an unlabeled, undated bag. The Dietary Manager acknowledged both issues and confirmed that proper cleaning and food storage procedures were not followed.
Staff did not consistently use required PPE when providing care to a resident on enhanced barrier precautions for wounds and a urinary catheter. Despite signage and available PPE, several staff members transferred the resident without wearing gowns and gloves, citing unfamiliarity with the residents or not noticing the signage. Interviews revealed gaps in staff understanding of EBP and infection control protocols, and there was no monitoring in place to ensure PPE compliance.
A resident with severe cognitive impairment and multiple diagnoses had a privacy curtain with a dried brown substance that remained unreported and uncleaned for several days. Staff interviews revealed that all staff were responsible for reporting soiled curtains to maintenance for cleaning, but this process was not followed, resulting in the curtain remaining dirty despite facility policy requiring immediate laundering or replacement.
A resident receiving enteral nutrition via a gastrostomy tube was found to have their feeding pump set at a higher rate than ordered by the physician. Nursing staff and facility policy required verification of the correct rate, but this was not done, resulting in the resident receiving nutrition at an incorrect rate until the error was identified and reported.
A resident with severe cognitive impairment received wound care from an RN who failed to change gloves and perform hand hygiene between the dirty and clean phases of the procedure. Despite the facility's infection control policy and staff training, this lapse was observed, highlighting a deficiency in maintaining a safe and sanitary environment.
The facility failed to implement comprehensive care plans for three residents, affecting their ability to receive necessary care. A resident with moderate cognitive impairment lacked a care plan for her Apixaban medication. Another resident with severe cognitive impairment did not have a care plan for his Foley catheter, and a third resident with neurological conditions lacked a care plan for her medications. The interdisciplinary team, including the MDS Coordinator and DON, did not update the care plans, impacting care continuity.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy due to the absence of physician orders and inadequate maintenance of oxygen equipment. The resident, with chronic obstructive pulmonary disease, did not have an active order for oxygen use, and the nasal cannula and humidifier were not changed weekly as required. Staff were unaware of these deficiencies, and the facility lacked a policy on oxygen treatment, placing the resident at risk for respiratory issues.
The facility failed to ensure accurate documentation and administration of narcotic medications for two residents, leading to discrepancies in narcotic counts on two medication carts. Nurses admitted to not logging narcotics immediately after administration, citing being busy as the reason. Interviews revealed that the facility's policy required end-of-shift narcotic counts, which were not consistently followed.
The facility failed to properly label and store medications, resulting in expired drugs on a medication cart and unsecured eye drops at a resident's bedside. Nursing staff did not consistently check for expired medications, and a resident's previous order to keep eye drops at the bedside was not renewed, posing risks of overmedication and access by others.
The facility failed to maintain sanitary practices in the kitchen due to the dishwashing machine not performing at the optimal sanitation rate. The absence of chlorine and the use of expired and incorrect test strips were observed. Dietary staff, including the Dietary Manager, were unaware of the correct ppm required and the importance of using non-expired test strips. As a result, lunch was served using disposables. The facility's policy and the U.S. Public Health Service Food Code were not adhered to, posing potential health risks for residents.
The facility failed to obtain necessary physician orders for two residents, impacting their care. One resident lacked orders for flushing a gastrostomy tube between medications, while another had no specified catheter size in their orders. The LVN and ADON acknowledged these omissions, which could lead to improper care. The facility's policy requires immediate recording of verbal orders, which was not followed.
The facility failed to ensure accurate advance directives for two residents, leading to inconsistencies in their code status records. One resident had a care plan indicating full code status without an active physician order, while another had a DNR status without an order. Staff interviews revealed gaps in maintaining accurate records, with the DON acknowledging that orders might have been missed during readmissions.
A medication error occurred when an LVN failed to flush a resident's gastrostomy tube between medications, resulting in an 8.57% error rate. The resident's orders only specified flushing before and after medication administration, not between, leading to potential risks of tube blockage and medication interactions. Interviews revealed that the facility's policy required flushing between medications, but the orders were incomplete.
A resident with severe cognitive impairment and multiple medical conditions, including a pressure ulcer, did not receive proper incontinence care. Staff used multiple briefs, contrary to protocol, to manage heavy urination and prevent urine from reaching a pressure wound. This practice, acknowledged by staff to potentially cause skin breakdown, was not addressed by facility leadership despite awareness of the issue.
The facility failed to report a resident-to-resident altercation involving a serious injury within the required 2-hour timeframe. One resident with severe cognitive impairment was attacked by another resident with dementia, resulting in a head laceration that required staples. The incident was not reported to the State Survey Agency until the next day, violating federal regulations.
A treatment cart containing medications and supplies was left unattended and unlocked in a hallway, allowing unauthorized access. The assigned LVN was unaware the cart was unsecured while assisting with incontinent care. The facility's policy requires carts to be locked when not in use.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent an accident involving a resident with dementia and schizophrenia. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 8, was allowed to sit outside the front of the building unsupervised after the receptionist left for the day. Despite being assessed as a moderate risk for wandering, the resident was not identified as an elopement risk prior to the incident and was not provided with the necessary supervision to prevent her from leaving the facility premises. On the day of the incident, the resident was last seen approximately 15 minutes before being found walking down the street with her walker, away from the facility. She was observed by a former staff member, who notified facility staff. The resident was subsequently approached and escorted back to the facility by staff without injury. Interviews with staff and the responsible party revealed that the resident had not previously attempted to leave the facility, but she was known to enjoy sitting outside and sometimes expressed confusion or a desire to wait for family members. The facility's staff, including CNAs, LVNs, and administrative personnel, reported that they were aware of policies regarding elopement and wandering, but the resident was not considered an elopement risk before this event. The receptionist, who typically monitored the resident while she was outside, had left and asked the resident to come inside, but the resident remained unsupervised. This lapse in supervision allowed the resident to leave the facility grounds unnoticed, resulting in the deficiency.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report highlights lapses in the standard of care required to address and mitigate pressure ulcer risks.
Failure to Obtain Informed Consent Prior to Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of antipsychotic medications. Record review showed that the resident, who had moderate cognitive impairment and diagnoses including depression and Alzheimer's Disease, began receiving Olanzapine and Aripiprazole as ordered by the physician. However, the consent forms for these medications were not signed by the responsible party until several weeks after the medications had already been administered. There was no documentation of verbal consent being obtained prior to the administration of the first doses. Interviews with facility staff revealed that the ADONs were responsible for obtaining consents before administering antipsychotic medications, and that the process sometimes involved obtaining verbal consent over the phone, which should be documented with the date. The responsible party for the resident did not recall giving consent or discussing the medications over the phone. Additionally, the facility administrator was unable to provide a policy regarding consents for antipsychotic medications at the time of the survey.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, specifically in scheduling an appointment for dentures, despite being aware of the resident's edentulous status and her expressed desire for dentures. The resident, an elderly female with chronic kidney disease, non-Alzheimer's dementia, diabetes mellitus, and schizophrenia, was admitted without upper or lower teeth and required a mechanical soft diet. Her care plan identified dental problems and included interventions such as daily oral care and referral to social services for dental follow-up. Documentation showed that the social worker attempted to initiate a dental referral by leaving a voicemail but did not follow up further for at least five weeks. During interviews, the resident reported being bothered by the lack of teeth and expressed a strong desire for dentures. The Social Services Director acknowledged responsibility for scheduling dental appointments and admitted not having contacted the referred dental company or determined the necessary documentation, citing lack of time. The Administrator confirmed that follow-up on dental referrals was the Social Services Director's responsibility, with ultimate accountability falling to the Administrator if not completed. Facility policy required contact with outside vendors within three business days of referral initiation, which was not met in this case.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically in the walk-in cooler where a dark substance measuring approximately 12 inches by 4 inches was found on the non-porous floor. The Dietary Manager acknowledged that the substance had built up over the years and had not been cleaned, stating that nothing had been attempted to remove it. The Dietary Manager also indicated that it was his responsibility to ensure the kitchen was clean and sanitary, but believed the substance did not affect residents' health since it was not in direct contact with food. Additionally, the facility failed to properly store and discard food items in the freezer. A clear, unlabeled, and undated sealed plastic bag containing previously defrosted and re-frozen ground beef was found, with a puddle of frozen blood inside. The Dietary Manager confirmed that the ground beef should not have been re-frozen and that this practice could put residents at risk of foodborne illness. The meat had been placed in the freezer by a new cook who was unaware of proper procedures, and the Dietary Manager had not noticed the item prior to the survey. Review of the facility's policy confirmed that thawed products should not be refrozen and that refrigeration units should be kept clean.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident who was on enhanced barrier precautions (EBP) due to wounds and a urinary catheter. Observations showed that on multiple occasions, staff members transferred the resident between bed and wheelchair without wearing the required gown and gloves, despite clear signage indicating the need for PPE and the presence of PPE supplies nearby. Interviews revealed that some staff were unfamiliar with the residents on EBP, did not notice the signage, or did not understand the meaning of EBP, leading to lapses in infection control practices. The resident involved was an elderly female with a history of leg fracture with surgical repair, dementia, and kidney failure, requiring assistance with activities of daily living and placed on isolation precautions for a surgical wound. The facility had several residents on isolation for various reasons, and signage was used to indicate EBP status. Staff interviews indicated inconsistent knowledge and adherence to PPE protocols, and the Director of Nursing confirmed that while in-services on infection control were provided, there was no monitoring to ensure staff compliance with PPE use.
Failure to Maintain Clean Privacy Curtain in Resident Room
Penalty
Summary
A deficiency was identified when a resident's privacy curtain was observed to have a dried brown substance measuring approximately 0.5 cm x 1 cm. Multiple staff interviews confirmed that it was the responsibility of all staff to report soiled privacy curtains to the maintenance department, which would then remove, launder, and rehang the curtains. Despite this policy, the soiled curtain was not reported to the maintenance director, and the curtain remained dirty over multiple days of observation. Staff members, including CNAs, LVNs, and housekeeping, acknowledged the importance of keeping privacy curtains clean for infection control and resident dignity, but the required reporting and cleaning process was not followed in this instance. The resident involved was an elderly female with severe cognitive impairment, non-Alzheimer's dementia, anxiety, and stage 2 chronic kidney disease. She required supervision for activities of daily living and reported that the dirty curtain did not affect her daily life, partly due to poor vision. Review of facility policy confirmed that privacy curtains should be laundered or replaced immediately if soiled, but this procedure was not adhered to, resulting in a failure to maintain a sanitary and comfortable environment for the resident.
Failure to Follow Physician Orders for Enteral Feeding Rate
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident receiving enteral nutrition via a gastrostomy tube was provided care in accordance with physician orders. The resident, who had a history of nontraumatic intracerebral hemorrhage, diabetes mellitus, and dysphagia following a stroke, was observed with her feeding pump set at 60 ml/hr, despite a physician order specifying a rate of 50 ml/hr. The care plan and physician orders detailed the required formula, feeding rate, and water flushes, but these were not followed as observed during the survey. Interviews with nursing staff and review of facility policy confirmed that the enteral feeding pump rate should match the physician's order, and that it is the responsibility of nursing staff to verify and set the correct rate. The incorrect rate was identified by a nurse during rounds, who acknowledged the error and reported it to the ADON. Both the ADON and DON stated their expectations that nurses follow physician orders and verify pump settings during rounds, as outlined in facility policy. The failure to follow the physician's order for the enteral feeding rate constituted the deficiency.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of RN A during wound care for a resident. The resident, who was admitted with a traumatic subdural hemorrhage and had severe cognitive impairment, required substantial assistance with daily activities. During an observation, RN A did not change gloves or perform hand hygiene after removing the old dressing and cleaning the wound, before applying a new dressing. This lapse in protocol was acknowledged by RN A, who admitted to not washing hands between the dirty and clean phases of wound care. Interviews with other staff members, including an LVN, a CNA, the ADON, and the DON, revealed a general understanding of the importance of hand hygiene and glove changes during wound care. They all reported having received training on infection control and handwashing. The DON, who also serves as the facility's Infection Preventionist, emphasized the necessity of washing hands before, after, and in-between care, and acknowledged the risk of cross-contamination if these practices are not followed. The facility's handwashing policy, revised in August 2015, mandates the use of hand hygiene procedures to prevent the spread of infections. It specifies that hand hygiene should be performed before handling clean or soiled dressings and before moving from a contaminated to a clean body site. Despite this policy and the training provided, the failure to adhere to these procedures during the observed wound care session resulted in a deficiency in the facility's infection control program.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for three residents, which could affect their ability to receive necessary care and services. Resident #27, a female with moderate cognitive impairment and multiple diagnoses including hyperlipidemia, did not have a care plan addressing her Apixaban medication, prescribed to prevent blood clots and strokes. This oversight was noted in her records, which lacked documentation of the medication order in her care plan. Resident #39, a male with severe cognitive impairment and an indwelling catheter, did not have a care plan addressing his Foley catheter. His physician's orders specified a monthly catheter change, but the care plan did not reflect this requirement, nor did it specify the catheter size. During an observation, Resident #39 was found in a hospital emergency unit without a Foley catheter, highlighting the lack of proper documentation and care planning. Resident #52, a female with progressive neurological conditions and multiple medications, did not have a care plan addressing her current medication orders, including Mirtazapine, Donepezil, and Seroquel. The facility's interdisciplinary team, including the MDS Coordinator and DON, were responsible for updating care plans, but the necessary updates were not made, potentially affecting the continuity of care for these residents.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the absence of physician orders for the resident's oxygen use. The resident, an elderly female with intact cognition, had multiple active diagnoses including chronic obstructive pulmonary disease, which necessitated the use of oxygen. Despite this, there was no active physician's order for oxygen therapy, and the resident's care plan indicated the need for oxygen as ordered. This oversight was confirmed through record reviews and interviews with staff, who acknowledged the lack of an order and the responsibility of the admitting nurse to ensure all necessary orders were entered. Additionally, the facility did not adhere to professional standards regarding the maintenance of the resident's oxygen equipment. Observations revealed that the resident's nasal cannula and humidifier were not changed weekly as required, with the nasal cannula appearing discolored and undated. Interviews with the resident and staff confirmed that the nasal cannula had not been replaced for several weeks, and the humidifier bottle's date was illegible. Staff members, including an LVN and the ADON, admitted to being unaware of the lack of equipment maintenance and the absence of a physician order, which could lead to infection or inadequate oxygen delivery. The facility's failure to provide a policy on oxygen/respiratory treatment and to follow physician orders further compounded the issue. The DON was not aware of the missing orders and emphasized the importance of obtaining physician orders to ensure proper care. The lack of a policy and the failure to follow established procedures for changing the nasal cannula and humidifier bottle weekly were significant factors contributing to the deficiency, placing the resident at risk for respiratory concerns.
Inaccurate Narcotic Documentation and Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate documentation and administration of narcotic medications for two residents. On two medication carts, the narcotic logs for two residents were found to be inaccurate. For one resident, the narcotic administration record showed a discrepancy between the logged and actual count of Acetaminophen with Codeine tablets. The nurse involved admitted to not logging the administration of the medication, attributing the oversight to being busy. Another resident's narcotic administration record for Tramadol also showed a discrepancy between the logged and actual count of pills. The nurse responsible for this resident's medication admitted to forgetting to sign off on the narcotic administration log after administering the medication. Both nurses acknowledged the importance of logging narcotics immediately after administration to prevent drug diversion and discrepancies. Interviews with the ADON and DON revealed that the facility's policy required nurses to count controlled medications at the end of each shift, with both the incoming and outgoing nurses participating in the count. However, it was found that the nurses did not consistently follow this policy, leading to discrepancies in narcotic counts. The facility had conducted in-services on medication administration and narcotic logging, but the staff failed to adhere to these procedures consistently.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, leading to deficiencies in medication management. Specifically, the medication cart for Hall C contained expired medications, including Naloxone tablets, Sodium chloride ophthalmic solution, Aspirin, Zinc sulfate capsules, Debrox ear drops, and Lispro insulin. Interviews with the LVN, ADON, and DON revealed that it was the responsibility of the nursing staff to check and remove expired medications each shift, but this was not consistently done. The expired medications posed a risk of reduced effectiveness. Additionally, a resident was found to have a bottle of eye drops stored unsecured at their bedside, contrary to facility policy requiring medications to be stored in locked compartments. The resident had previously been allowed to keep eye drops at the bedside, but this order was not renewed upon their return from the hospital. The ADON acknowledged the oversight and the risk it posed, including potential overmedication and access by other residents. The nursing staff, including the LVN, were unaware of the unsecured medication, indicating a lapse in monitoring and adherence to storage protocols. The facility's policy on discontinued medications emphasized the timely removal of such medications from the cart and maintaining storage areas in a clean and safe manner. However, the observations and interviews highlighted a failure to adhere to these policies, resulting in expired medications remaining in the cart and unsecured medications at a resident's bedside. This lack of compliance with established procedures contributed to the deficiencies identified during the survey.
Improper Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, specifically with the dishwashing machine, which was not performing at the optimal sanitation rate due to the absence of chlorine and the use of expired and incorrect test strips. Observations revealed that the dishwashing machine required 50 ppm chlorine, but the test strips used by Dietary Aides E and F were expired and the wrong type, with a first increment of 100 ppm. The chlorine container was found empty, and the staff had to contact maintenance to replace it, as they were unable to lift the heavy container themselves. Dietary Aide F, who had been working at the facility for about six months, admitted to not checking the expiration date of the test strips and was unaware of the correct ppm required for the dish machine. The Dietary Manager, who was responsible for ensuring the facility had the correct type of test strips, also did not know the correct ppm or that the test strips had expiration dates. The Dietary Manager attempted to locate another package of test strips, but they were also expired and incorrect. As a result, lunch was served using disposables because the correct test strips could not be located in time. Interviews with various staff members, including Dietary Aide E and the Cook, revealed a lack of proper training and awareness regarding the importance of using the correct and non-expired test strips. The Dietary Manager acknowledged that the dish machine log was probably inaccurate due to the use of expired and incorrect test strips. The Administrator confirmed that the proper test strips should be used and that the Dietary Manager was responsible for ensuring this was done. The facility's policy and the U.S. Public Health Service Food Code were not adhered to, leading to a risk of improper sanitation and potential health risks for residents.
Failure to Obtain Physician Orders for Medical Procedures
Penalty
Summary
The facility failed to obtain necessary physician orders for two residents, which could potentially impact their care. For one resident, there were no physician orders for flushing the gastrostomy tube with water between medication administrations. The resident, who had severe cognitive impairment and a feeding tube, was only receiving flushes before and after medication administration, as per the existing orders. The Licensed Vocational Nurse (LVN) acknowledged the absence of orders for flushing between medications and admitted to not performing the flushes due to the lack of orders. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were aware of the issue, with the ADON confirming the missing orders and updating them after being notified. Another resident, also with severe cognitive impairment, had an indwelling urinary catheter but lacked specific physician orders for the catheter size. The resident's care plan did not address the Foley catheter, and the physician's orders did not specify the size, leading the LVN to use a French size 18 catheter without consulting the physician. The LVN assumed the omission of the size was intentional and did not verify it, which could lead to inappropriate catheter use. The ADON and DON both recognized the oversight and the potential risks associated with not having a specified catheter size. The facility's policy on medication and treatment orders requires verbal orders to be recorded immediately, including the prescriber's details and the time of the order. However, this protocol was not followed in these cases, leading to the deficiencies noted. The physician involved stated that standard orders for gastrostomy tube flushing should be documented for any resident receiving medications through such a tube, and he expected the staff to update the orders accordingly.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure the residents' rights to formulate an advance directive for two residents, leading to inconsistencies in their code status records. Resident #2, an elderly female with intact cognition and multiple health conditions, had a care plan indicating a full code status. However, her physician order summary report did not have an active order to support this status. Similarly, Resident #27, also with intact cognition and various health issues, had a care plan indicating a Do Not Resuscitate (DNR) status, but her physician order summary report lacked an active order for this status. Interviews with facility staff revealed gaps in the process of maintaining accurate advance directive records. The Social Worker, who joined after the residents' readmissions, acknowledged the risk of not having advance directives in place. LVN G was unaware of the missing advance directive order in the electronic health record for Resident #2 and relied on paper documentation. The ADON admitted to not being aware of the missing orders and emphasized the importance of having orders in place to honor residents' wishes. The DON stated that advance directive orders should be established at admission and reviewed by the ADON and herself. She acknowledged that the orders might have been missed during the residents' last readmissions. The facility's policy requires providing residents with information about their rights to accept or refuse treatment and to formulate advance directives, but the lack of active orders for the two residents compromised the ability to honor their end-of-life wishes.
Medication Administration Error Due to Incomplete Flushing Procedure
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8.57% error rate due to the actions of LVN A. This error involved Resident #57, who had a gastrostomy tube and required specific flushing procedures during medication administration. LVN A did not flush the gastrostomy tube with water between medications, as there were no specific orders for this step, despite being aware of the standard practice. The resident's physician orders only included flushing the tube with 60 ml of water before and after medication administration, not between each medication. The deficiency was observed when LVN A administered medications to Resident #57 without flushing the gastrostomy tube between each medication, which could lead to tube blockage and medication interactions. Interviews with LVN A, the DON, and the ADON revealed that the facility's policy required flushing between medications, but the orders were missing this instruction. The DON and ADON acknowledged the oversight and the importance of following physician orders and facility policy to prevent such errors.
Improper Incontinence Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide proper incontinence care for a resident who was unable to perform activities of daily living independently. The resident, a male with severe cognitive impairment and multiple medical conditions including a urinary tract infection, pressure ulcer, and neuromuscular dysfunction of the bladder, required total dependence on staff for daily living activities. Despite the care plan indicating the need for incontinence care every two hours and as needed, the staff used multiple incontinence briefs on the resident, which was not in accordance with facility protocol. This practice was intended to prevent urine from traveling to the resident's sacral pressure wound but was acknowledged by staff to potentially cause skin breakdown and irritation. Interviews with various staff members, including an LVN, CNA, ADON, and DON, revealed awareness of the use of double briefs for the resident. The CNA initiated the use of two briefs to manage the resident's heavy urination and prevent urine from reaching the pressure wound. The ADON and DON were aware of this practice but did not instruct staff to discontinue it, despite recognizing the risks of skin breakdown and infection. The facility did not provide a specific policy on pericare or briefing procedures, which contributed to the deficiency in care.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. This deficiency was observed in the case of two residents involved in a physical altercation. The incident occurred between a resident with severe cognitive impairment and another resident with moderate cognitive impairment and behavioral issues. The altercation resulted in a serious injury to one of the residents, who sustained a laceration on her head that required staples. Despite the severity of the injury, the incident was not reported to the State Survey Agency within the required 2-hour timeframe. The incident took place when one resident, who was nonverbal and watching TV at the nurse's station, was attacked by another resident wielding a wooden back scratcher. The attacking resident, who had a history of dementia and psychosis, struck the nonverbal resident on the head, causing significant bleeding. The staff immediately intervened, called 911, and provided first aid. The injured resident was transported to the hospital for treatment and returned to the facility later that night. Despite the immediate response to the physical injury, the facility did not report the incident to the appropriate authorities within the mandated 2-hour window. The Director of Nursing (DON) and the Interim Administrator discussed the incident and decided to report it the next day, believing the injury was not serious enough to warrant immediate reporting. The DON did not consider the laceration to be a serious bodily injury and did not classify the incident as abuse due to the attacking resident's dementia. This misjudgment led to a delay in reporting the incident, which is a violation of the facility's policy and federal regulations. The facility's policy clearly states that any alleged violation involving abuse or resulting in serious bodily injury must be reported within 2 hours, a requirement that was not met in this case.
Unsecured Treatment Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents. Specifically, Treatment cart #1 was left unattended and unlocked in the facility's C-hall. The cart contained medications, treatment supplies, and treatment scissors. During the observation, three staff members and four residents passed by the unsecured cart. LVN A, who was assigned to the cart, was unaware that it was left unlocked while she was assisting with incontinent care in a resident's room. LVN A acknowledged that she was trained to lock the cart when not in use and recognized the potential risk of residents accessing the medications if the cart was left unsecured. The Director of Nursing (DON) and the Administrator were informed about the incident. Both confirmed that it was the facility's policy and expectation for nursing staff to secure all medication and treatment carts when not in use. The facility's policy on the security of medication carts, revised in April 2007, mandates that carts must be locked to prevent unauthorized entry. The policy also specifies that carts should be parked in the doorway of the resident's room or against the hallway wall with doors and drawers facing the wall, and must be locked before the nurse enters the resident's room. The failure to adhere to this policy was identified as a deficiency during the survey.
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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) |
|---|---|---|---|---|
| Arbrook Plaza | 0.6 mi | ★★★★★ | 12 | 0 |
| Avir At Arlington | 4.1 mi | ★★★★★ | 13 | 3 |
| Green Oaks Nursing & Rehabilitation | 4.2 mi | ★★★★★ | 1 | 0 |
| Matlock Place Health & Rehabilitation Center | 4.3 mi | ★★★★★ | 10 | 2 |
| Viridian Wellness & Rehabilitation | 4.3 mi | — | 41 | 0 |
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