Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlin Springs Health & Rehabilitation during CMS and state inspections, most recent first.
Care plans were not fully implemented for three residents. One resident on Eliquis had a care plan for bleeding monitoring, but the record did not show monitoring for anticoagulant side effects. Another resident with chronic pain received the wrong opioid medication when Hydromorphone was given instead of Methadone. A third resident with a 1500 mL fluid restriction exceeded the ordered limit on multiple days, despite the care plan and physician order.
A facility failed to meet professional standards when staff gave a resident’s omeprazole late on multiple occasions, did not follow an ordered fluid restriction for a resident with ESRD and CHF, failed to document late benazepril administration correctly for a cognitively intact resident, and made a medication error in which an LPN gave hydromorphone instead of methadone to a resident receiving opioid pain meds. The record also did not show the hourly monitoring described after the error.
A facility failed to maintain a clean and homelike environment for three cognitively intact residents. One room had a stained storage bin and stained privacy curtain, another had dead roaches left on the floor after pest treatment, and a third had about 25 rodent droppings on the floor that remained during repeated observations. The DON, housekeeping, and maintenance staff acknowledged the conditions.
A facility failed to follow its abuse policy during an abuse investigation involving a resident after the resident’s spouse alleged verbal abuse and neglect by an LPN. The investigation documents stated the LPN was verbally abusive and mocking toward the resident, but the record did not show the LPN was re-assigned or suspended while the allegation was being investigated, and the LPN continued providing care to the resident.
A resident’s scheduled Gabapentin doses were not available for administration, with two doses documented as not given because the medication was not delivered from the pharmacy and a prescription was needed. The eMAR showed the medication ordered for neuropathy, and nursing notes plus an LPN interview described the pharmacy-related delay and the facility’s process for obtaining medications when unavailable.
A resident with chronic pain and cauda equina syndrome received the wrong opioid and dose when an LPN/nurse gave hydromorphone instead of the ordered methadone. The resident’s opioid orders included hydromorphone 8 mg q4h and methadone 30 mg TID, but the nurse administered three 8 mg hydromorphone tablets when methadone was intended. The error was later documented in the chart and confirmed by staff interviews and the medication error report.
Care Plan Not Developed or Implemented for Medication Monitoring, Opioid Administration, and Fluid Restriction
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for three residents. For one resident with atrial fibrillation who had a physician order for Eliquis 5 mg every 12 hours, the care plan identified a risk for bleeding and bruising related to anticoagulant use and directed staff to observe for signs and symptoms of abnormal bleeding, bruising, or black tarry stools and report to the MD as indicated. However, the clinical record for the following months did not show physician orders or documentation that the resident was monitored for anticoagulant side effects. For another resident with arthritis, chronic back pain, and chronic pain unrelieved by analgesics, the care plan for opioid use directed staff to administer medications as ordered. The physician orders included Hydromorphone 8 mg every 4 hours for pain and Methadone 10 mg, 3 tablets three times a day for chronic pain. On 1/27/26, a nurse documented that three tablets of Hydromorphone were given in error instead of three tablets of Methadone at about 0600, and the resident was informed, assessed, and monitored after the medication error. For a third resident with diagnoses including metabolic encephalopathy, cirrhosis of the liver, and acute pancreatitis, the care plan documented a fluid restriction of 1500 mL per day with interventions to follow the physician order and keep no water at bedside. The physician order specified fluid restriction of 1500 mL by mouth and via med pass each shift, but review of the MARs showed that the resident exceeded the ordered fluid restriction on 19 of 26 days in June 2026 and 16 of 21 days in July 2026.
Medication Administration and Order Compliance Deficiencies
Penalty
Summary
The facility failed to meet professional standards of practice in medication administration for multiple residents. For one resident with GERD, omeprazole delayed-release 40 mg scheduled for 5:00 p.m. was administered late on multiple dates in December 2022, including several doses given more than an hour after the scheduled time and one dose not given. Facility staff stated that medications should be administered within one hour before or after the scheduled time, and the facility policy required confirmation of the 5 rights, including the right time, during medication administration. The facility also failed to follow an ordered fluid restriction for a resident with ESRD, pulmonary edema, congestive heart failure, and metabolic encephalopathy. The physician’s order specified a 1-liter fluid restriction with 360 mL by mouth three times daily with meals and 140 mL per shift nursing allowance. Staff reviewed the order and stated that the resident was receiving more fluid than ordered and that the order totaled 1500 mL, which should have been clarified with the provider. The care plan also reflected the fluid restriction and related interventions. For another resident with hypertension and lymphedema, the facility failed to document and code late administration of benazepril correctly. The medication administration audit showed that benazepril was given more than two hours late on three dates, but the MAR did not reflect that the medication was not administered at the ordered time. Staff interviews confirmed that scheduled medications should be given within one hour of the ordered time and that late administration should be documented in the MAR with the reason for the delay. The facility also failed to follow professional standards after a medication error involving a resident receiving opioid pain medications. The resident was ordered hydromorphone 8 mg every 4 hours and methadone 10 mg, 3 tablets three times daily for chronic pain. Instead of methadone, the nurse gave 3 tablets of hydromorphone 8 mg at about 6:00 a.m. The resident was documented as alert, oriented, and stable after the error, and the record showed provider and family notification, but the clinical record did not evidence the hourly monitoring of vital signs and clinical status described in the provider note, nor did it show timely provider notification before the unit manager arrived.
Unclean Resident Rooms and Unsanitary Conditions
Penalty
Summary
The facility failed to provide a clean and homelike environment for three residents who were cognitively intact and able to make daily decisions. For one resident, observation of the room showed a white plastic storage bin with dried brown material on the lower right side and a privacy curtain with two stained areas, including one quarter-sized stain and one approximately six inches long. The resident stated that staff came in almost every day to mop and clean up, but he did not know whether the curtain was ever changed. The Director of Housekeeping later observed the curtain and furniture and stated that both needed cleaning or replacement. For another resident, dead roaches were observed on the floor along the headboard of the bed and behind the dresser and TV stand. The resident stated there had been an ongoing roach problem in the room for a while and that the room had last been treated about two weeks earlier. The resident also stated that the dead roaches had been on the floor for awhile and housekeeping had not cleaned them all up. Review of pest control logs showed the room had recently been treated, and the maintenance director and Director of Housekeeping both acknowledged that the dead roaches remained on the floor and that housekeeping had missed them. For a third resident, approximately 25 rodent droppings were observed on the floor in the narrow space between the bed and the wall. The droppings remained present during repeated observations over multiple times. The Director of Environmental Services stated that resident room floors should be swept and mopped every day and disinfected if rodent droppings are observed, and also stated that rodent droppings on the floor are not clean or homelike.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse policy to protect a resident during the investigation of an abuse allegation involving Resident #162. The facility policy stated that when a specific staff member is identified as being allegedly involved in an abuse allegation, that staff may be re-assigned or suspended during the investigation. The facility’s synopsis of events documented an initial report on 11/11/2025 after the administrator received an email from the resident’s wife alleging abuse and neglect, and the internal investigation was completed on 11/18/2025. The investigation folder included a Summary of Issues at [Name of facility] stating that Nurse LPN #10 had been verbally abusive and mocking toward Resident #162, including making fun of him in front of other staff and residents, causing him to cry and be afraid of her. The final five-day investigation summary documented an abuse investigation with police notification and an interview of Resident #162, who voiced no concerns regarding nursing staff, but the record did not show that LPN #10 was re-assigned or suspended during the investigation. The clinical record showed LPN #10 continued caring for Resident #162 on 11/12/2025, 11/15/2025, and 11/16/2025. During interview, the DON stated that the former Administrator had received the spouse’s email and that they reported and investigated the allegation, and she stated that normally the employee would have been suspended when named in an abuse allegation.
Medication Unavailable for Scheduled Gabapentin Doses
Penalty
Summary
The facility failed to ensure Gabapentin was available for administration for Resident #156. The resident’s eMAR for 10/1-10/31/2022 showed Gabapentin 100 mg ordered every 8 hours for neuropathy, but on 10/14/2022 the 6:00 AM dose and the 10:00 PM dose were documented as not given. The 10:00 PM dose on 10/13/2022 and the 2:00 PM dose on 10/14/2022 were documented as administered. Nursing notes stated the 6:00 AM dose was not administered because it was not delivered from the pharmacy, and the 10:00 PM dose was not administered because a prescription was needed. During an interview, an LPN stated that medication orders were faxed to the pharmacy on admission and that if medications were not available, staff could call the pharmacy to send them stat. The facility policy on unavailable medications stated that nursing staff shall notify the attending physician or on-call physician and explain the circumstances, expected availability, and alternative therapies available.
Wrong Opioid and Dose Administered to Resident
Penalty
Summary
The facility failed to ensure that one resident was free from a significant medication error when the resident was given the wrong opioid medication at the wrong dose. The resident had diagnoses including cauda equina syndrome and chronic pain syndrome, and the physician orders called for hydromorphone 8 mg by mouth every 4 hours for pain and methadone 30 mg by mouth three times daily for chronic pain. The eMAR showed hydromorphone scheduled throughout the day and methadone scheduled at 7:00 AM, 3:00 PM, and 11:00 PM. On the morning of the incident, the nurse intended to administer methadone 30 mg but instead gave three tablets of hydromorphone 8 mg, totaling 24 mg, by mouth. The resident was documented as alert and oriented, with stable vital signs after the error was discovered. The nurse notified the incoming nurse and unit manager, and the nurse practitioner was contacted later that morning. The resident’s daughter was also notified by phone. The record further documented that the nurse practitioner assessed the resident later that day for accidental overdose and noted that the resident had received hydromorphone instead of methadone. The resident remained alert and awake and was described as clinically stable. The medication error report and staff interviews confirmed that the wrong opioid and wrong dose had been administered, and the facility’s medication administration policy required confirmation of the 5 rights during medication administration.
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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) |
|---|---|---|---|---|
| Goodwin House Bailey's Crossroads | 0.8 mi | ★★★★★ | 0 | 0 |
| The Jefferson | 1.6 mi | ★★★★★ | 43 | 3 |
| Goodwin House Alexandria | 1.9 mi | ★★★★★ | 0 | 0 |
| Cherrydale Health & Rehabilitation Center | 2.7 mi | ★★★★★ | 7 | 0 |
| Annandale Healthcare Center | 3.1 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.