Inspection Reports for
Arlington Gardens Care Center

The facility was found deficient in multiple areas including failure to obtain timely informed consent for psychotropic medications, lack of documentation supporting schizophrenia diagnosis, improper medication administration and storage, failure to monitor anticoagulant side effects, inadequate infection control practices, and improper food storage. Several residents were affected by these deficiencies, but harm was generally minimal or potential.

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, inadequate documentation supporting schizophrenia diagnosis, medication administration errors, improper medication storage and labeling, failure to monitor anticoagulant side effects, infection control lapses, and food safety violations.

The complaint investigation was triggered by a quality care issue regarding medication administration. The deficiency was substantiated based on observation, interviews with LVN 1, LVN 2, and the Director of Nursing, and record review of Resident 1's medication administration records.

The facility failed to ensure medication administration was conducted according to professional standards when LVN 2 prepared and administered medications to Resident 1 but did not sign the medication administration record, resulting in inaccurate documentation and potential medication errors.

The complaint investigation was triggered by a quality care issue regarding medication administration for Resident 1. The allegation was substantiated based on observation, interviews, and record review.

The facility failed to ensure medication administration was conducted according to professional standards when LVN 2 prepared and administered medications to Resident 1 but did not sign the medication administration record, resulting in inaccurate documentation and potential medication errors.

The complaint investigation focused on Resident 1, who was discharged to an unlicensed room and board without adequate supervision or care, despite requiring constant supervision and a pureed diet. The facility did not verify the safety or appropriateness of the discharge location. The resident was later hospitalized with a urine infection. Additionally, the facility failed to maintain accurate clinical records, including improper family notification and questionable signatures on the Notice of Proposed Discharge. Immediate jeopardy was identified and later removed after the facility implemented a removal plan.

The facility failed to verify that the receiving environment for Resident 1 could meet her care needs, resulting in discharge to an unlicensed room and board without caregivers or understanding of medical requirements, creating immediate jeopardy to resident health and safety. Additionally, the facility failed to maintain complete and accurate clinical records, including improper documentation of family notification and signatures on discharge notices.

The complaint investigation substantiated that the facility discharged a cognitively impaired resident to an unlicensed room and board without proper supervision or verification of care needs, creating immediate jeopardy. The investigation also found failures in clinical record keeping, including inaccurate documentation of family notification and signatures on discharge notices.

The facility failed to ensure a safe and appropriate discharge for a resident with dementia and dysphagia, discharging her to an unlicensed room and board without caregivers or knowledge of her medical needs, creating immediate jeopardy. Additionally, the facility failed to maintain complete and accurate clinical records, including improper documentation of family notification and signatures on discharge notices.

The complaint investigation found substantiated failures in grooming, foot care, and supervision for residents, specifically Resident 1 and Resident 3, leading to potential risks of skin injuries and accidental falls.

The facility failed to provide adequate grooming and foot care for Resident 1, who had long fingernails and toenails, and failed to provide adequate supervision for Resident 3, who experienced four falls within seven days. These failures posed risks for avoidable skin injuries and accidental injuries.

The investigation was complaint-driven, focusing on inadequate grooming and foot care for Resident 1 and insufficient supervision for Resident 3, who experienced multiple falls. The complaints were substantiated based on observations, interviews, and record reviews.

The facility failed to provide adequate grooming and foot care for Resident 1, resulting in long fingernails and toenails that posed a risk for skin injuries. Additionally, the facility failed to provide adequate supervision for Resident 3, who experienced four falls within seven days, increasing the risk of serious injury.

The complaint was related to the transfer and discharge process. It was substantiated that the facility did not send the proposed transfer/discharge notice to the Ombudsman at the same time it was provided to the resident or representative for Residents 3 and 8.

The facility failed to provide the proposed transfer and discharge notice to the Office of the State Long-Term Care Ombudsman at the same time the notice was given to the resident or resident's representative for two of 23 sampled residents. This failure resulted in a missed opportunity for the Ombudsman to advocate for the residents to ensure a safe and appropriate discharge.

The complaint investigation was triggered by concerns about the transfer and discharge process, specifically the timing of notices sent to the Ombudsman compared to residents and their representatives. The complaint was substantiated with findings of delayed notice to the Ombudsman.

The facility failed to provide the proposed transfer and discharge notice to the Office of the State Long-Term Care Ombudsman at the same time the notice was given to the resident or resident's representative for two of 23 sampled residents, resulting in a missed opportunity for advocacy to ensure a safe and appropriate discharge.

The facility failed to ensure staff followed infection control policies for masking, including two CNAs wearing N95 masks over surgical masks and one CNA caring for a Covid-19 positive resident without proper N95 fit testing. These failures posed a risk of increased exposure and transmission of Covid-19 to staff and residents.

The facility failed to ensure that staff followed infection control policies for masking. Two Certified Nursing Assistants wore N95 masks over surgical masks, and one CNA cared for a COVID-19 positive resident without proper N95 fit testing, increasing potential exposure risks.

The facility failed to ensure survey results were accessible to residents and family, timely completion and accuracy of Minimum Data Set (MDS) assessments, accurate PASARR Level I screenings, documentation of medication allergies, prevention of resident elopement, posting of daily direct care staffing, and maintaining medication error rates below 5%. Several residents were affected by these deficiencies.

The facility failed to ensure survey results were accessible to residents, timely and accurate completion of Minimum Data Set (MDS) assessments, accurate PASARR Level I screenings, documentation of medication allergies, prevention of resident elopement, posting of daily direct care staffing, and maintaining medication error rates below 5%.

The facility failed to ensure survey results were accessible to residents, timely completion and accuracy of Minimum Data Set (MDS) assessments, accurate PASARR screenings, documentation of medication allergies, prevention of resident elopement, posting of daily direct care staffing, and maintaining medication error rates below 5%. Several residents were affected by these deficiencies.

The facility had multiple deficiencies including failure to make survey results accessible to residents, untimely and inaccurate Minimum Data Set (MDS) assessments, inaccurate PASARR screenings, failure to document medication allergies, resident elopement resulting in emergency room visit, failure to post daily direct care staffing, and a medication error rate exceeding 5%.

The complaint investigation focused on admission, transfer, and discharge rights. It was substantiated that the resident was discharged to an incorrect address, which was a facility rather than the family member's home. The Social Service Director confirmed the address only after transportation had taken the resident to the wrong location.

The facility failed to ensure a safe and orderly discharge for one resident when the discharge location was not confirmed with the family before transfer, resulting in the resident being sent to the wrong address. The issue was identified through interviews and record reviews, revealing discrepancies in address confirmation and communication.

The complaint investigation was related to admission, transfer, and discharge rights. The complaint was substantiated as the facility failed to confirm the discharge address with the family, resulting in the resident being sent to an incorrect facility address.

The facility failed to ensure a safe and orderly discharge for one resident when the discharge location was not confirmed with family before transfer, resulting in the resident being sent to the wrong address. The issue was identified through interviews and record reviews showing lack of address confirmation between May 22 and May 29, 2024.

The investigation was complaint-driven, focusing on allegations related to call light accessibility, transfer/discharge notification failures, and missed scheduling of follow-up medical appointments. The complaints were substantiated based on observations, interviews, and record reviews.

The facility failed to ensure Resident 9 had the call light within reach, failed to provide timely and complete notices of proposed transfer/discharge and notify the Ombudsman for Residents 4, 5, and 7, and failed to schedule follow-up cardiology and pulmonology appointments for Resident 8. These failures posed potential risks to residents' safety, rights, and health.

The visit was complaint-driven, investigating allegations related to call light accessibility, transfer/discharge notifications, and scheduling of medical follow-ups. The complaints were substantiated with findings of failures in these areas.

The facility failed to ensure Resident 9 had the call light within reach, failed to provide timely notices of proposed transfer/discharge and notify the Ombudsman for Residents 4, 5, and 7, and failed to schedule follow-up cardiology and pulmonology appointments for Resident 8. These failures had the potential to cause harm or delay in care for the affected residents.

The complaint investigation was initiated after it was found that Resident 2 was discharged improperly without notifying the responsible party or ombudsman, and was sent to a board and care that refused admission. Resident 2 was later found outside the second board and care facility and required emergency hospital care.

The facility failed to provide timely and updated notification to the resident's responsible party and the Long-term Care Ombudsman regarding changes in the discharge location. Additionally, the resident was discharged to a board and care facility that refused admission, resulting in the resident being found outside the facility and requiring emergency hospital care.

The complaint investigation was initiated due to failure to notify Resident 2's family and Ombudsman of changes in discharge location, resulting in unsafe discharge and unnecessary hospital transfer. The complaint was substantiated based on interviews and record reviews.

The facility failed to provide an updated notice of transfer and discharge for Resident 2's responsible party and the Ombudsman, resulting in Resident 2 being discharged to a board and care that refused admission, then transferred to another board and care unaware of the resident's arrival. This led to Resident 2 being found outside the facility and requiring emergency hospital care. The facility did not follow normal discharge protocols and failed to notify the family and Ombudsman of the new location.

This was a re-investigation of a quality care concern complaint. The grievance was reported by Resident 1's family member regarding an incident at a doctor's office. The complaint was partially substantiated as the facility failed to inform the family of investigation results.

The facility failed to ensure Resident 1's representative was informed of the investigation findings regarding an incident at a doctor's appointment where the resident had a change of condition and was transferred to an acute care hospital. The Director of Nursing investigated but did not confirm if the family member was informed of the results.

The visit was complaint-related, triggered by a grievance filed by Resident 1's family member regarding the resident's condition change at a doctor's office and subsequent hospitalization. The grievance investigation was incomplete in communication with the family member.

The facility failed to ensure Resident 1's representative was informed of the investigation findings regarding an incident at a doctor's appointment where the resident's condition changed and required hospital transfer. The Director of Nursing investigated but did not confirm if the family member was informed of the results.

The investigation was initiated due to a complaint about quality-of-care issues related to medication administration and pain monitoring for Resident 2. The complaint was substantiated by record review and interviews.

The facility failed to document the time, date, medication name, and dosage of a medication on the Medication Administration Record (MAR) and failed to monitor pain relief for one of three sampled residents (Resident 2). This failure had the potential for Resident 2 to receive extra doses of pain medication or no medication, resulting in increased pain.

The complaint was related to a quality-of-care issue involving failure to properly document medication administration and pain monitoring for Resident 2. The complaint was investigated during an unannounced visit on February 28, 2024.

The facility failed to document the time, date, medication name, and dosage of a pain medication on the Medication Administration Record (MAR) and did not monitor pain relief for Resident 2 as required. This failure had the potential for Resident 2 to receive extra doses or no medication, resulting in increased pain.

The visit was complaint-related, investigating quality of care issues including failure to notify physicians, failure to assist with scheduled surgery, inadequate pain medication supply, and failure to properly assess and document wounds and pressure injuries.

The facility failed to notify the physician of a wound on Resident 2's left shin, failed to assess and monitor the wound, and did not document treatment changes or weekly evaluations for a pressure injury. The facility also failed to assist Resident 1 in attending scheduled eye surgery and did not ensure an adequate supply of pain medication was available for Resident 1.

The investigation was initiated due to complaints regarding quality of care issues including wound care, access to scheduled surgery, and medication availability for residents.

The facility failed to notify the physician of a wound on Resident 2's left shin, failed to assess and monitor the wound, and did not document treatment changes or weekly evaluations for a pressure injury. Resident 1 experienced delayed eye surgery due to lack of transportation scheduling and had an inadequate supply of pain medication (Norco) for 48 hours, causing unrelieved pain.

The investigation was triggered by a complaint regarding an incident on November 21, 2023, where Resident 2 entered Resident 1's room naked and attempted to kiss her three times. The complaint was substantiated based on interviews and observations.

The facility failed to ensure one resident was free from abuse when another resident attempted to kiss her multiple times. The incident occurred due to lack of proper supervision after a sitter was sent home when a resident returned from the hospital.

The investigation was triggered by a complaint regarding Resident 2's inappropriate sexual behavior toward Resident 1. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to ensure Resident 1 was free from abuse when Resident 2, who had severely impaired cognition and no sitter assigned after returning from the hospital, attempted to kiss Resident 1 multiple times. Staff acknowledged that a sitter was not provided to Resident 2 upon return from the hospital, which could have prevented the incident.

The investigation was initiated due to a complaint regarding resident rights and care. The complaint was substantiated based on findings that the facility failed to provide required written bed-hold notice and failed to prevent gastrostomy tube dislodgement.

The facility failed to provide written notice of the bed-hold policy to Resident A or her representative during hospital transfer and return. Additionally, the facility did not implement interventions or a care plan to prevent dislodgement of Resident A's gastrostomy tube, resulting in the tube being pulled out and Resident A being sent to the hospital for reinsertion.

The complaint investigation focused on Resident A's rights and care, specifically regarding failure to provide bed-hold notice and failure to prevent gastrostomy tube dislodgement. The complaint was substantiated with findings of minimal harm.

The facility failed to provide written notice of the bed-hold policy to Resident A or her representative during hospital transfer, and failed to implement interventions or a care plan to prevent dislodgement of Resident A's gastrostomy tube, resulting in the tube being pulled out and Resident A being sent to the hospital for reinsertion.

The investigation was triggered by complaints regarding resident's rights and discharge rights. Resident A was denied the right to go out on pass without a physician's order and left AMA. The complaint was substantiated with findings that the facility did not honor resident rights and failed to document discharge planning adequately.

The facility failed to honor a resident's right to go out on pass without a physician's order, failed to conduct an assessment and obtain a physician's order for self-administration of medications, and failed to ensure appropriate documentation and planning for discharge. These failures potentially compromised resident rights, medication safety, and post-discharge care.

The investigation was triggered by complaints regarding resident's rights and discharge rights. Resident A was denied going out on pass without a physician's order despite prior passes and left the facility AMA. The facility lacked documentation supporting denial and discharge planning. The complaint was substantiated with findings of rights violations and documentation failures.

The facility failed to honor Resident A's right to go out on pass without a physician's order, failed to conduct an assessment and obtain a physician's order for self-administration of medications, and failed to ensure appropriate discharge planning documentation. These failures resulted in Resident A leaving the facility AMA and potential risks to safe medication administration and post-discharge care.

The complaint alleged that Resident 1 was transported late for surgery on September 7, 2023, causing the surgery to be rescheduled and increasing infection risk. The facility stated Resident 1 refused surgery, but Resident 1 denied refusal. The complaint was investigated through interviews and record reviews.

The facility failed to transport Resident 1 on September 7, 2023, causing the surgery to be rescheduled and resulting in the resident having dialysis through a tunneled central venous catheter, which posed a potential infection risk. Conflicting statements were noted regarding whether Resident 1 refused the surgery.

The complaint alleged that Resident 1 was transported late for surgery on September 7, 2023, causing the surgery to be rescheduled and increasing infection risk. The facility stated Resident 1 refused surgery, but the complainant and Resident 1 denied refusal.

The facility failed to transport Resident 1 on time for surgery on September 7, 2023, causing the resident to require dialysis through a tunneled central venous catheter, which increased the risk of infection. Conflicting statements were noted regarding whether Resident 1 refused surgery, with the complainant and resident denying refusal.

The complaint investigation included a resident rights issue regarding delayed release of medical records and a quality care issue related to diabetes management for two residents. The investigation found substantiated delays in record release and failures in diabetes care including inconsistent blood sugar monitoring and insulin administration without proper checks.

The facility failed to provide requested resident records timely for one resident, causing delays in record utilization. Additionally, the facility failed to implement proper diabetes management for another resident, with inconsistent blood sugar monitoring, multiple conflicting insulin orders, and insulin administration without blood sugar checks, posing potential harm.

The complaint investigation was substantiated, revealing delays in releasing resident records and failures in diabetes care management, including lack of blood sugar monitoring and insulin administration errors.

The facility failed to provide requested resident records timely, delaying their use. Additionally, the facility failed to implement proper diabetes management for one resident, with inconsistent blood sugar monitoring and multiple conflicting insulin orders, risking medication errors and potential harm.

The investigation was triggered by a complaint related to Resident A's elopement. The complaint was substantiated as the facility failed to monitor and reassess the resident before reducing sitter hours.

The facility failed to ensure that Resident A was assessed and monitored prior to reducing sitter hours during the night shift, which resulted in Resident A eloping from the facility. There was no documented evidence of monitoring or re-assessment before reducing sitter hours, violating facility policy on resident supervision.

The complaint investigation was triggered by a reported elopement incident involving Resident A. The investigation found the complaint substantiated due to failure in monitoring and reassessment prior to sitter hour reduction.

The facility failed to ensure Resident A was assessed and monitored prior to reducing sitter hours during the night shift. This failure resulted in Resident A eloping and had the potential to cause injury or harm.

The complaint investigation was triggered by a quality-of-care complaint regarding pressure ulcer care. The investigation found the complaint substantiated with failures in wound care, documentation, and timely physician notification.

The facility failed to implement appropriate interventions to prevent the development of a Stage 3 pressure injury in one resident, resulting in minimal harm and increased risk for pain and infection. Documentation and timely assessments were lacking, and the wound care specialist was not contacted promptly despite worsening condition.

The investigation was triggered by a quality-of-care complaint concerning pressure ulcer care. The complaint was substantiated with findings of inadequate wound care and documentation.

The facility failed to implement appropriate interventions to prevent the development of a Stage 3 pressure injury in one resident. Documentation and timely assessments were lacking, and the physician was not notified promptly when the wound worsened.

The investigation was triggered by complaints regarding staffing concerns, specifically delayed call light responses and failure to provide scheduled bathing. Interviews with residents and staff confirmed these issues, and substantiation is implied by the findings.

The facility failed to ensure call lights were promptly answered for three of five residents, resulting in residents getting up unassisted and potential delayed medical management. Additionally, four of five sampled residents did not receive showers or baths as scheduled, with documented periods of 5-10 days without bathing and lack of proper documentation or notification of refusals.

The investigation was triggered by complaints regarding delayed call light responses and failure to provide scheduled bathing for residents. The complaint was substantiated based on interviews and record reviews.

The facility failed to ensure call lights were promptly answered for three of five residents, resulting in potential delayed medical management and unmet care needs. Additionally, four of five sampled residents did not receive showers or baths as scheduled, potentially affecting their physical and psychosocial well-being.

The complaint investigation focused on the facility's failure to properly document and communicate discharge reasons and bed-hold policy notifications for Resident A. The complaint was substantiated with findings of inadequate documentation and communication.

The facility failed to document and communicate the reason for Resident A's discharge to the general acute care hospital and did not provide written notice of the bed-hold policy duration to the resident or responsible party. These failures had the potential to cause emotional distress and loss of resident rights to secure bed-hold benefits.

The facility failed to ensure respiratory tubing was replaced after seven days as required by policy, potentially exposing residents to bacterial growth. This deficiency was observed in one of two residents reviewed for oxygen use.

The complaint was substantiated as the facility did not follow its policy to replace respiratory tubing every seven days. The failure was confirmed through observation, interviews with nursing staff, and record review.

The facility failed to ensure respiratory tubing was replaced every seven days as required, potentially risking bacterial growth affecting residents. Interviews and observations confirmed the tubing was used beyond the recommended replacement period.

The investigation was complaint-driven, focusing on failure to notify the physician about Resident 1's low blood pressure readings. The complaint was substantiated based on record reviews and staff interviews.

The facility failed to ensure the physician was notified of low blood pressure readings for one resident on multiple occasions. Licensed nurses did not recheck or report abnormal vital signs as required by facility policy.

The investigation was complaint-driven, focusing on failure to notify the physician of Resident 1's low blood pressure. The complaint was substantiated based on record review and staff interviews.

The facility failed to ensure the physician was notified of low blood pressure readings for one resident on multiple occasions. Licensed nurses did not recheck or report abnormal vital signs as required by facility policy.

The complaint investigation focused on Resident A's discharge process and bed-hold notice. It was substantiated that the facility failed to document discharge communication and failed to provide written bed-hold notice to the resident or responsible party.

The facility failed to document and communicate the reason for Resident A's discharge to the general acute care hospital, resulting in a difficult discharge and potential emotional distress. Additionally, the facility did not provide written notice to Resident A or the responsible party specifying the duration of the bed-hold policy upon transfer to the hospital.

The facility had multiple deficiencies including failure to develop comprehensive care plans, inadequate monitoring and treatment of residents, medication administration discrepancies, improper medication storage and labeling, expired food items, and failure to maintain infection control practices such as timely IV dressing changes.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for IV catheter sites, inadequate monitoring of bowel movements, improper respiratory care, medication administration discrepancies especially with controlled substances, lack of physician orders and care plans for oxygen use, improper medication storage and labeling, failure to monitor for bleeding in residents on warfarin, expired food items in refrigerators, and failure to change IV catheter dressings timely.