Purehealth Transitional Care at Thr Arlington

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 2 medication carts (Hall [NAME] nurses' medication cart) reviewed for pharmacy services. The facility failed to ensure expired medications were removed from the Hall [NAME] nurses' medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #12, Resident #58, Resident #159, and Resident #160) reviewed for infection control. RN A failed to disinfect vital signs equipment between each resident while performing morning medication administration for Resident #12, Resident #58, Resident #159, and Resident #160. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of five residents reviewed for notification. - The facility failed to notify Resident #1's physician when the resident's vitals were abnormal on 2/24/25, 2/25/25, 2/26/25, and 2/27/25. It was also documented and reported to nursing staff that Resident#1 was lethargic and fatigued throughout the week by staff and the resident's family. Resident #1 was sent to the local hospital on 2/28/25 where she was diagnosed with sepsis from a UTI, after the family alerted RN A that the resident's blood pressure was critically low. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. -The facility failed to document assessments and notify the physician when Resident #1's vitals were abnormal on 02/24/25, 2/25/25, 2/26/25, and 2/27/25. There were also no interventions when staff and Resident #1's family expressed concerns about the resident being lethargic and fatigued throughout the week. Resident #1 was sent to the local hospital on 2/28/25 where she was diagnosed with sepsis from a UTI, after the family alerted RN A that the resident's blood pressure was critically low. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Patient #1) of 6 patients reviewed for ADLs. -The facility failed to provide showers or bed baths and oral care consistently for Patient #1 according to the facility's ADL schedule. This failure could place all patients who require assistance with ADL care at risk for poor personal hygiene, odors and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality for one of six residents (Resident #1) reviewed for post-surgical care. RN A and LVN C failed to obtain doctor's order for Resident #1 who was admitted with a tube connected to her stomach to drain an abscess on [DATE]. Resident #1's post-surgical site, stomach drain tube, and output were not documented from admission [DATE] through [DATE] when Resident #1 required hospitalization due to infection. RN A and LVN C were not trained on how to manage a drain. RN A and LVN C did not know why they did not obtain an order for the drain. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:00 pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care. The facility failed to ensure Resident #1's stomach drain tube and drainage bag were documented on admission to the facility on [DATE] and accurately assessed, monitored, and treated. The drain was identified on [DATE] when family mentioned the stomach tube drainage to the physician and four days later on [DATE], Resident #1 required hospitalization due to infection. The facility failed to ensure the surgeon was notified for Resident #1's missing orders for drain tube monitoring. An Immediate Jeopardy (IJ) was identified on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made. If the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 8 residents (Resident #193) reviewed for neglect reporting. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #139) of five residents reviewed for quality of care. The facility failed to identify a significant change of condition in Resident #139 between 03/14/24 to 03/19/24. This failure could place residents at risk for diminished quality of care and worsening conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate administration of medications for 1 of 1 resident observed for medication administration. (Resident # 34) RN A administered an incorrect dose of Acetaminophen to Resident #34. This failure could place the 11 residents who received medications administered by RN A at risk of not receiving the intended therapeutic benefit of their medications.