Arlington Care Center

Based on observation, interview, and medical record review the facility failed to ensure one, (Resident #37) received timely assistance with facial grooming. This affected one of two reviewed for activities of daily living (ADL). The facility census was 97Findings include:Review of Resident #37's medical record revealed an admission date of 02/05/26. Medical diagnoses include encounter for other orthopedic aftercare, nondisplaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing, need for assistance with personal care, wedge compression fracture of unspecified lumbar vertebrae, chronic kidney disease stage III, Alzheimer's disease, and essential primary hypertension.Review of Resident 37's admission Minimum Data Set (MDS) 3.0 dated 02/11/26 revealed a Brief Interview for Mental Status (BIMS) score which was noted as not completed due to Resident #37 is rarely/never understood. Review of functional abilities note Resident #37 requires substantial/maximal assistance with personal hygiene.Review of Resident #37's bath/shower sheets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #102 received services for her vision. This affected one, (Resident #102) of one resident viewed for communication and sensory. The facility census was 97.Findings include: Review of Resident #102's medical record revealed an admission date of 09/25/24 with diagnoses including end stage renal disease, type two diabetes mellitus, hemiplegia and hemiparesis affecting left nondominant side, major depressive disorder, anxiety disorder, and anemia.Review of Resident #102's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and adequate vision.Review of Resident #102's Healthdrive request for service, dated 10/03/24, revealed the resident had requested to be seen by eye care.Review of Resident #102's physician order dated 11/04/25 revealed an order to be treated as needed by podiatrist, dentist, or optometrist.Review of Resident #102's plan of care on 02/25/26 revealed it did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview the facility failed to provide timely podiatric care for one, (Resident #79) of two reviewed for activities of daily living (ADL). The census was 97.Findings include:Review of Resident #79 ' s medical record revealed an admission date of 11/21/25. Diagnoses include spinal stenosis lumbar region without neurogenic claudication, wedge compression fracture of T 9-T 10 (thoracic) vertebra subsequent encounter for fracture with routing healing, Type II Diabetes Mellitus with diabetic polyneuropathy, and essential primary hypertension.Review of Resident 79 ' s admission Minimum Data Set (MDS) 3.0 dated 02/05/26 revealed a Brief Interview for Mental Status (BIMS) score of seven. Review of functional abilities revealed Resident #79 required substantial/maximal assistance with putting on/taking off footwear.Review of Resident #79 ' s care plan dated 02/03/26 confirmed Resident #79 may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. Resident #79 is assisted with all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to obtain weekly weights for Resident #37 who was a new admission and at nutritional risk. This affected one (Resident #37) of two residents reviewed for nutrition. The census was 97.Findings include: Review of Resident #37's medical record revealed an admission date of 02/05/26. Medical diagnoses include encounter for other orthopedic aftercare, nondisplaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing, need for assistance with personal care, wedge compression fracture of unspecified lumbar vertebrae, chronic kidney disease stage III, Alzheimer's disease, and essential primary hypertension.Review of Resident 37's admission Minimum Data Set (MDS) 3.0 dated 02/11/26 revealed a Brief Interview for Mental Status (BIMS) was not completed noting Resident #37 is rarely/never understood. Review of functional abilities revealed Resident #37 required partial/moderate assistance with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review the facility failed to ensure Resident #13's blood pressure medications were not administered outside of parameters. This affected one resident (#13) of five residents reviewed for unnecessary medications. The facility census was 97.Findings include: Review of Resident #13's medical record revealed an admission date of 09/03/24 with diagnoses including Type Two Diabetes Mellitus, chronic obstructive pulmonary disease, chronic heart failure, and acquired absence of right leg. Review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition.Review of Resident #13's plan of care dated 09/13/24 revealed the resident had altered health maintenance related to diagnoses including atherosclerotic heart disease and hypertension. Interventions included administering medications as ordered.Review of Resident #13's physician order dated 09/12/24 revealed an order for Carvedilol tablet 3.125 milligrams…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to implement safety interventions for Resident #37. This affected one (Resident #37) out three residents reviewed for accidents. The facility census was 103.Findings include:Review of Resident #37's medical record revealed an admission date of 08/31/22 with diagnoses including but not limited Alzheimer's disease, chronic kidney disease, high blood pressure, anxiety, and depression.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had impaired cognition, required assistance from staff to complete activities of daily living (ADL) tasks including personal hygiene care, was incontinent of urine and bowel, and used a wheelchair for mobility.Review of Resident #37's alteration in skin integrity care plan dated 09/09/22 revealed an intervention for geri-sleeves (protective sleeves) to bilateral arms as tolerated and staff to offer and encourage resident to wear long sleeves at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of a test tray, resident and staff interview, and policy review, the facility failed to ensure food was served at a palliative and warm food temperature. This affected Residents #11, #77, and #80 and had the potential to affect all residents who received meals from the kitchen except Resident #1 and Resident #99 who were nothing-by-mouth (NPO). The facility census was 94. Findings include: Interview with Resident #77 on 07/08/24 at 11:01 A.M. stated the food was cold. Resident #77 said they have warmers, but they were not using them at all meals. Resident #77 said the breakfast was normally cold. Interview with Resident #80 on 07/08/24 at 11:26 A.M. revealed the food was terrible, not appealing, and cold by the time it gets to them. Resident #80 also said the breakfast was always the same eggs and toast or pancakes and sausage. Interview with Resident #11 on 07/09/24 a 10:19 A.M. revealed the food doesn't agree with her. She said a lot of times the food was cold when they get it. Observation of the tray line was made on 07/11/24 at 8:23 A.M. with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, staff interview and facility policy review, the facility failed to maintain appropriate infection control practices in the area of isolation and enhanced barrier precautions (EBP). This affected two residents (#77 and #84) of 24 residents on isolation and/or EBP. Additionally, the facility failed to ensure proper hand hygiene was completed in between contact with each resident while serving meal trays. This had the potential to all nine residents (Resident #198, #86, #30, #199, #200, #74, #72, #63, and #201) residing on the facility's C unit who received a meal tray. The facility census was 94. Findings include: 1. Review of the medical record for Resident #77 revealed an initial admission date of 02/21/24 with the diagnoses including hydronephrosis with renal and ureteral calculous obstruction, artificial openings of urinary tract infection (UTI), and chronic kidney disease. Review of the admission assessment and baseline care plan dated 02/21/24 revealed Resident #77 had a right nephrostomy tube in place. Review of the plan of care dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #24, Resident #58 and Resident #350, who required staff assistance for activities of living (ADL) care received timely assistance with nail care to maintain proper grooming. This affected three residents (#24, #58 and #350) of three residents reviewed for ADL care. The facility identified 71 residents who required assistance with grooming and hygiene. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 12/09/21 with diagnoses including chronic kidney disease, obesity, coronary artery disease, major depressive disorder, dementia and hallucinations. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/10/22 revealed Resident #24 required extensive assistance from one staff for dressing and hygiene. Review of the plan of care, dated 06/10/22 revealed Resident #24 may require assistance with ADLs. Interventions include to provide assistance with bathing and grooming based on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #37 was provided timely and adequate assistance with eating, a nutritional diet was provided as ordered and meal intakes were documented for Resident #37 who was identified to have a significant weight loss in one month. This affected one resident (#37) of five residents reviewed for nutrition. Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including pressure ulcer to the sacral area, chronic obstructive pulmonary disease, dementia, sleep apnea and depression. Review of the dietary assessment, dated 07/06/22 at 1:06 P.M. revealed Resident #37 was on a regular diet with finger foods because she would not use silverware. The assessment revealed the meal should provide approximately 2473 calories and 95 grams of protein daily. The resident feeds herself with poor intakes of approximately 25-50 percent of most meals documented. Her current body weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #37 had oxygen on to maintain her oxygen saturation above 90 percent as ordered. This affected one resident (#37) of eight residents who were ordered oxygen on unit one. Finding include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including pressure ulcer to the sacral area, chronic obstructive pulmonary disease, dementia, sleep apnea and depression. Review of the Minimum data Set (MDS) 3.0 assessment, dated 07/07/22 revealed Resident #37 had severely impaired cognition, required total assist from one staff member for dressing and personal hygiene, extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for eating. Review of the August 2022 physician's orders revealed Resident #37 had an order for oxygen at two liters via nasal cannula continuously to maintain oxygen saturation (above 90%) and to check oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.