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 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 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 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 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 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 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 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 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 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.

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 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 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 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 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 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 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 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 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 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 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 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 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 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.