Arlington Gardens Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the resident's medical records within two working days of the written request to the law firm representing the resident's legal representative (POA - Power of Attorney) for one of four residents reviewed (Resident 1). In addition, the facility followed an outdated policy which was effective during the COVID-19 Public Health Emergency, which expired in [DATE]. This failure resulted in the violation of Resident 1's exercise of her legal rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and treatment according to professional standards of practice for three of 19 residents (Residents 123, 5, and 126) when:1. For Resident 123, a bottle of open, unlabeled Equate (equivalent to Afrin) nasal spray (medication used to relieve stuffiness from colds, allergies, and sinus pressure (feeling of fullness, pain, or tightness in the face) was found at bedside without a physician's order. This failure had the potential for Resident 123 to receive ineffective treatment that could lead to serious health problems.2. For Resident 5, one open, unlabeled box of Salonpas medication pads (topical pain relievers used to provide temporary relief to minor muscle aches, joint pain, back aches, strains, and sprains) was found at the bedside with no physician's order for administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (controlled substances, those with high potential for abuse and addiction) when:The Controlled Substance Records (CSR, accountability records) for two of four randomly selected residents (Residents 4 and 108) did not reconcile with the Medication Administration Records (MAR, daily documentation record used by a licensed nurse to document medications and treatments given to a resident),The CSR did not match the narcotic (controlled substances used to treat pain) medication contents for one of four randomly selected residents (Resident 123) in Medication Cart 1, andThe facility did not implement appropriate disposal of fentanyl (narcotic pain medication that is 100 times more potent than morphine) patches for one of one randomly selected residents (Resident [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8.82% when three medication errors occurred out of 34 opportunities during the medication administration observation for three out of five residents (Residents 36, 111, and 69). These failures resulted in medications not given according to the physician's orders and had the potential for residents to experience side effects such as nausea, upset stomach, and gastric irritation (inflammation of the stomach lining).1. During a medication pass observation on January 5, 2026, at 9:07 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed administering four medications to Resident 36. The medications included one tablet of metformin (medication to treat diabetes) 1000 milligrams (mg). LVN 1 asked Resident 36 if he had eaten breakfast yet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for four of nineteen residents reviewed for infection control practices (Residents 125, 36, 111, and 69) when:1. For Resident 125, the nasal cannula tubing was not changed according to facility policy.2. For Residents 36, 111, and 69, shared equipment was not disinfected with the appropriate disinfectant between residents. These failures had the potential to expose residents to infection and compromise residents' health and safety in the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for two of five sampled residents (Residents 5 and 19) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents or their representatives to not be fully informed of the risks and benefits of psychotropic medications before receiving treatment. 1. Resident 5 had a physician's order, dated March 19, 2025, for buspirone (generic for Buspar, a medication to treat anxiety) 5 milligrams (mg), Give 1 tablet by mouth three times a day for anxiety, restlessness. [...]

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards when one of five sampled residents (Resident 19) did not have documentation to support a diagnosis of schizophrenia (a mental illness characterized by disturbances in thought). This failure had the potential for unnecessary and inappropriate use of antipsychotic (medications to treat mental illness like schizophrenia) medications. A review of Resident 19's admission Record, printed on January 8, 2026, indicated the resident was admitted to the facility from the hospital on December 10, 2025, with diagnoses including dementia (a progressive state of decline in mental abilities). The record also indicated Resident 19 had a previous admission to the facility on December 30, 2024. Resident 19 had physician's orders, dated December 10, 2025, for the following medications: [...]

Inspectors wroteBased on an observation, interview, and record review, the facility failed to follow its established smoking policy for one of one residents reviewed (Resident 20) when smoking materials were not stored in a locked container as required by the facility's policy. This failure had the potential to create environmental risk, hazards and accidents such as fire and/or burn injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided for one of two residents reviewed for nutrition (Resident 92), when the physicians order to stop fluid restriction was not observed by the nursing and kitchen staff timely. This failure had the potential for Resident 92 to not have her preferences honored, and/or lead to weight loss and compromised nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 123) was free of unnecessary medications when side effects were not monitored with the administration of an anticoagulant (blood thinner). This failure had the potential for undetected bleeding and harm to residents. Resident 123 had a physician's order, dated December 27, 2025, for heparin (an anticoagulant medication), to Inject 5000 unit subcutaneously [under the skin] every 8 hours for DVT [deep vein thrombosis, type of blood clot] prophylaxis [prevention]. During an interview on January 7, 2026, at 12:40 p.m., the Director of Nursing (DON) stated all residents on anticoagulants, including heparin, were monitored for bleeding and bruising. During a concurrent interview and record review on January 7, 2026, at 1:18 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and manufacturer's specifications when:1. One room temperature medication was inappropriately stored in the refrigerator in one of one reviewed medication rooms (Medication room [ROOM NUMBER]),2. One expired medication was stored in one of one reviewed medication rooms (Medication room [ROOM NUMBER]), and3. One inhaler was not labeled with an open date in one of two reviewed medication carts (Medication Cart 1). These deficient practices had the potential for inadequate medication monitoring, which could lead to the use of unsafe and ineffective medications for the residents. 1. During a concurrent observation and interview on [DATE], at 3:05 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food safety when one unopened carton of 237 ml (milliliter - a unit of measurement) Boost (nutritional supplement) with an expiration date of September 24, 2025, was found stored in residents' refrigerator # (number) 1 located in nurse's station 1. This failure had the potential to cause foodborne illnesses when consumed by a medically vulnerable resident.

Inspectors wroteBased on observation, interview, and record review on one of three residents (Resident 1) reviewed for medication administration, the facility failed to ensure medication administration was conducted in accordance with professional standards of practice when LVN 2 prepared and administered some of Resident 1's medications but did not sign the medication administration record. This failure resulted in inaccurate medication administration record and had the potential for Resident 1 and/or other residents for medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who required constant supervision and a pureed diet due to dementia and dysphagia, was discharged to a safe and appropriate setting. The facility did not verify that the receiving environment could meet the resident's care needs and discharged the resident to an unlicensed room and board with no caregivers and no understanding of her medical requirements. The facility's failure to ensure a safe and appropriate discharge for Resident 1 created an immediate jeopardy to resident health and safety. Without immediate intervention, other residents could be discharged to unlicensed or unsafe settings without necessary supervision, posing an ongoing and likely risk of serious harm, injury, or death. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records for one of four residents reviewed (Resident 1) when:1. Resident 1's Notice of Proposed discharged (Notice of Proposed Discharge - a written document from a healthcare facility that informs a resident and/or their representative of the facility's intent to end the resident's stay) issued on September 30, 2025 (the day of discharge), had signatures of the resident and her family. Resident 1 was cognitively impaired. In addition, Resident 1's family was not present when the NOPD was issued;This failure resulted in Resident 1 and her family not being able to exercise their right to appeal the proposed discharge to the state long-term care agency.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming was provided when one resident (Resident 1) who was observed with long fingernails did not receive on-going grooming services. This failure had the potential for Resident 1 to be at risk for avoidable skin injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foot care was provided when one resident (Resident 1) who was observed with long toenails and did not receive on-going podiatry (foot care provided by a specialty doctor) care. This failure had the potential for Resident 1 to be at risk for avoidable skin injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supervision and monitoring was provided for one resident (Resident 3) when Resident 3 fell on four separate occasions within seven days. This failure had the potential for Resident 3 to experience avoidable accidental injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide the proposed transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time the notice was provided to the resident and/or resident's representative in accordance with the policy and procedure for two of 23 sampled residents (Residents 3 and 8). This failure resulted in missed opportunity for the LTC Ombudsman to advocate for the residents to ensure a safe and appropriate discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the infection control policy and procedure for masking was followed when: 1. Two Certified Nursing Assistants (CNA) used an N95 mask (a protective device used to achieve a very close facial fit and very efficient filtration of airborne particles) over a surgical mask (face mask); and 2. One CNA used an N95 mask while caring for a Covid 19 (a highly infections respiratory virus) positive resident without a fit test(specialized test to determine the proper fit of a specific N95 for an individual). These failures had the potential to increase staff and resident exposure and transmission of the Covid 19 virus resulting in illness.

Inspectors wrote2. An admission Record revealed the facility admitted Resident #18 on 01/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified psychosis not due to a substance and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had diagnoses of depression (other than bipolar) and psychotic disorder (other than schizophrenia). Resident #18's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 01/01/2024, revealed the resident did not have a serious diagnosed mental disorder such as depression or symptoms of psychosis. [...]

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for 1 (Resident #37) of 19 resident MDS assessments reviewed.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (Residents #103) of 19 residents reviewed for accurate assessments.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure a medication allergy was documented for 1 (Resident #256) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure a resident was safe from eloping from the facility for 1 (Resident #91) of 3 residents reviewed for elopements. The failure resulted in Resident #91 leaving the facility during an excessive heat wave, leading to a visit to the emergency room.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate less than 5 percent (%) with a medication error rate of 7.69%. The facility had two medication errors out of 26 opportunities which affected 1 (Resident #29) of 4 residents observed for the medication administration task.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to ensure the survey results were accessible to residents and family members. This had the potential to affect all 98 residents that resided in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the daily direct care staffing was posted. This had the potential to affect all 98 residents that resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge was provided for one of three sampled residents (Resident 1), when the discharge location was not confirmed with family before transferring the resident. This failure had the potential for Resident 1 to be discharged to the wrong address which could cause anxiety to the family and to the resident.

Inspectors wroteBased on interview, and record review, the facility failed to provide an updated notice of transfer and discharge for one of three residents' (Resident 2) responsible party (RP) and the Long-term Care Ombudsman office to indicate the changes to the discharge location for Resident 2. This failure had the potential for Resident 2's RP and the Ombudsman not to be aware and be able to advocate for Resident 2's safe discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge for one of three residents (Resident 2), when Resident 2 was discharged to a Board and Care that had not accepted the resident for admission, then was transferred to another Board and Care that was unaware of the resident going to their facility. This failure caused Resident 2 to have unnecessary transfer to the general acute care hospital.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Resident 1's representative was informed of the findings of the investigation related to the incident which occurred while the resident was at a doctor's appointment. Resident 1 had a change of condition while at the doctor's office and had to be transferred to the acute care hospital. This failure had the potential for the family member or representative not to be aware of the circumstances surrounding the concern they had and to have unresolved issues.

Inspectors wroteBased on interview and record review, the facility failed to initiate and provide notices of proposed transfer/discharge (NOPD- a form that will indicate the notification of resident and reason for transfer/discharge) to three out of 4 residents, Resident 4, 5, and 7 and/or their responsible parties. In addition, the facility failed to notify the Long-Term Care Ombudsman (an advocate for residents and families in long-term care facilities) of Residents 4, 5, and 7's transfer/discharge from the facility. These failures had the potential for Residents 4, 5, and 7 to be unable to reach the Ombudsman. In addition, these failures caused the Ombudsman the inability to ensure Residents 4, 5 and 7 rights were protected.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of four residents, Resident 9, had the call light button within his reach. This failure had the potential to result in Resident 9 not being able to call for help.

Inspectors wroteBased on interview and record review, the facility failed to ensure that, for one of two residents, Resident 8, follow-up appointments with a cardiologist (a physician who is an expert in the care of the heart) and pulmonologist (a physician who is an expert in the care of the lungs) were scheduled. This failure had the potential to result in Resident 8 to have delayed treatments and additional increased risk of health complications.

Inspectors wroteBased on interview and record review the facility failed to document the time, date, medication name and dosage of a medication on the Medication Administration Record (MAR) and monitor for 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of the presence a wound on the left shin for one of three sampled residents (Resident 2). This failure had the potential to result in delayed provision of treatment resulting in worsening of Resident 2's left shin wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 2) left shin wound was assessed and monitored. This failure had the potential to result in worsening of Resident 2 ' s wound on the left shin.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was able to go to her scheduled eye surgery. This failure caused Resident 1 experiencing delayed eye surgery and feel anxious and upset.

Inspectors wroteBased on observation, interview and record review, the facility failed to document the reason for the change of treatment, modify the care plan and perform weekly evaluations of a pressure injury (breakdown of skin integrity due to pressure) for one of three sample residents (Resident 2). These failures had the potential to result in worsening of Resident 2 ' s pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure an adequate supply of pain medication was available for one of three sampled residents (Resident 1) reviewed. This failure had the potential to result in Resident 1 to have unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 1) was free from abuse when Resident 2 attempted to kiss Resident 1. This failure had the potential for Resident 1 to experience emotional distress due to inappropriate sexual behavior of Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of bed-hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization) was provided to the resident/and or resident representative, for one of three residents reviewed (Resident A) when Resident A was transferred to the acute hospital. This failure had the potential for the resident or resident representative not to be informed of their right to hold the bed while out of the facility and the right to be readmitted back to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions were put in place to prevent dislodgement of a gastrostomy tube (GT - a tube inserted through the stomach to provide food and medications), for one of three residents reviewed (Resident A) when the resident had behavior of grabbing onto her gastrostomy tube. This failure resulted in Resident A having her GT pulled out and sent to the hospital for reinsertion.

Inspectors wroteBased on interview and record review, the facility failed to honor resident's request to go Out on Pass (leaving a nursing home or skilled nursing facility (SNF) for non-medical reasons is usually referred to as therapeutic leave [defined as a home or family visit to enhance psychosocial interaction]), for one of three residents (Resident A) reviewed. This failure resulted in Resident A's rights not being honored and the resident left the facility AMA (Against Medical Advice).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment and evaluation for self-administration of medications was conducted, for one of three residents reviewed (Resident A). This failure had the potential to result in an unsafe administration of medications for Resident A.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate documentations to support discharge plan to include preparation for safe discharge, continuity of care, and post discharge follow-up were documented in the resident's clinical record, for one of three residents reviewed (Resident A). This failure has the potential for Resident A's post-discharge care needs not to be met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the copy of requested records was provided timely for one of four sampled residents (Resident 2). This failure had resulted in the delay to utilize the record in whatever purposes they meant to use the record for. Findings. On September 5, 2023, at 11:00 a.m., an unannounced facility visit was conducted to investigate a resident's rights issue. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement standard of care for management of diabetes mellitus (DM- a condition that affects the way the body processes blood sugar) for one of four sampled residents (Resident 1); when blood sugar was not consistently monitored and there were multiple different orders for blood sugar monitoring and physician ordered insulin injections. These failures had the potential to result in confusion causing medication errors subsequently causing a negative effect on the resident's medical condition.

Inspectors wroteBased on interview, and record review, the facility failed to transport one of four residents, (Resident 1) in a timely manner for a surgical procedure to place a dialysis, (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to), fistula, (a surgical connection between an artery and a vein for dialysis). This failure caused the resident to have dialysis through a tunneled central venous catheter (CVC - a type of access used for hemodialysis. are placed under the skin and into a large central vein, preferably the internal jugular veins. CVCs are meant to be used for a short period of time until a more permanent type of dialysis access has been established), which had a potential for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmacy services to meet the needs of the residents by not ensuring: 1. The nursing staff administering medications to have complete accountability of the movement of controlled substances (CS; medications that are tightly controlled by the government due to abuse and addiction) from accessing from the locked medication carts to the administration to residents and/or disposition of CS. The nursing staff failed to document the administration of medications on the electronic medication administration record (eMAR) for five of five residents' records reviewed (Residents 199, 200, 15, 11, and 58); This failure had the potential for drug diversion. 2. The nursing staff notified the physician of the high blood sugar measurement as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment that meets professional standards for food service safety when: 1. Multiple bottles of thickened dairy drink stored in the kitchen refrigerator were found expired; and 2. Multiple food items stored in the two refrigerators, dedicated for the facility residents at the nurse stations, were found expired. These failures had the potential to result in food-borne illness in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person centered care plan specific to the care and treatment of the intravenous (IV - a tubing placed in the vein to deliver fluids or medications) catheter site for one of five residents reviewed (Residents 36). This failure had the potential to place Resident 36 at risk for the development of infection and complications when measurable goals and desired outcomes were not achieved towards the proper care and services for the IV catheter site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure daily monitoring of resident's bowel movement was implemented for one resident reviewed (Resident 296). This failure resulted in Resident 296 having discomfort and feeling bloated when she did not have a bowel movement for two days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for three of three residents reviewed for oxygen use (Residents 25, 97, and 198) when: 1. For Resident 25, the nasal cannula (a tube used to deliver oxygen through the nose) was not replaced after seven days, and the humidifier (provides moisture for resident comfort during oxygen therapy) was empty; 2. For Resident 97, the humidifier mask was left exposed on top of the humidifier machine; and 3. For Resident 198, oxygen was administered without a physician's order, oxygen tubing was unlabeled, and there was no care plan for oxygen use. These failures had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents' health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents were free from unnecessary medications when an anticoagulant, warfarin (a blood thinner), was administered to Resident 50 without adequately monitoring for signs and symptoms of bleeding. This had the potential for the resident to experience fatal bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage and labeling of medications conformed to national standards and the facility's policy and procedure when: 1. One open acetylcysteine (medication used to loosen thick mucus) 20% vial did not have an open date; 2. One intact, unopened vial of Humulin R (insulin; medication used to control blood sugar) was stored not in the medication refrigerator but at room temperature in the drawer of the medication cart; and 3. Six vials of injectable lorazepam (medication used for anxiety) 2 mg/ml (milligram per milliliter; unit of measurement) for Resident 19 was kept in the medication refrigerator for residents' use. The medication order was discontinued on March 30, 2022. These failures could potentially result in residents receiving ineffective medication therapy from sub-potent medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's Intravenous (IV) catheter site dressing was changed according to the facility's professional standard of infection control practices for one of five residents reviewed (Resident 91). This failure resulted in Resident 91's right upper arm Peripherally Inserted Catheter (PICC) site dressing not being changed for 13 days. In addition this failed practice placed Resident 91 at risk for infection and other complications.