Serenity Spring Senior Living at Arlington

Inspectors wroteReview of Quality Assurance Performance Improvement (QAPI) sign-in sheets, interview, and policy review, the facility failed to ensure the medical director attended the meetings quarterly. This had the potential to affect all residents. The facility census was 44.

Inspectors wroteBased on medical record review, review of the infection control documentation, observation, staff interview, and policy review, the facility failed to ensure infection control standards were implemented in the facility for medication administration. This affected seven residents (#43, #19, #34, #16, #25, #2, and #47) of seven residents observed for medication administration. Furthermore, the facility failed to ensure infection surveillance in the facility. This had the potential to affect all residents. The facility failed to ensure Enhanced Barrier Precautions (EBP) and Contact Precautions (CP) signs were posted per the physician orders. This affected two residents (#3 and #15). Additionally, the facility failed to wear the appropriate Personal Protective Equipment (PPE) for residents in EBP and CP. This affected two (#28 and #46). The facility census was 44.

Inspectors wroteBased on review of the facility infection control binder, staff interview, and policy review, the facility failed to ensure McGeer's criteria/antibiotic stewardship were followed prior to administration of antibiotics. This had the potential to affect all residents. The facility census was 44.

Inspectors wroteBased on review of personnel files and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) had 12 hours of annual in-services as required. This affected three CNAs (#109, #110, and #162) of three CNA personnel files reviewed and had the potential to affect all 44 residents in the facility. The facility census was 44. Review of CNA #109's personnel file revealed a date of hire of 04/30/26. Further review of her personnel file revealed no evidence of any training hours since the last recertification survey on 04/18/24. Review of CNA #110's personnel file revealed a date of hire of 05/28/26. Further review of her personnel file revealed no evidence of any training hours since the last recertification survey on 04/18/24. Review of CNA #162's personnel file revealed a date of hire of 06/18/25. [...]

Inspectors wroteBased on review of Resident Council minutes, interviews, and policy review, the facility failed to respond to concerns in a timely manner and report to the council the steps taken to rectify any concerns. This affected six residents (#1, #3, #6, #18, #20, and #34) of six residents who regularly attended Resident Council meetings. The facility census was 44.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure a dignity bag was placed on a foley catheter bag. This affected one (#46) of one resident reviewed for foley catheters. The facility census was 44.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure comprehensive care plan reflected the residents' current status. This affected three (#15, #4, and #3) of 15 residents reviewed for care plans. The facility census was 44. 1. Review of medical record for Resident #15 revealed an admission date of 07/01/24 with diagnoses including but not limited to cognitive communication deficit, cerebral infarction, acute kidney failure, and adult failure to thrive. Review of physician orders revealed enhanced barrier precautions (EBP) for Extended-Spectrum Beta-Lactamase (ESBL) and cleanse left lower extremity (LLE) wound with wound cleanser, pat dry, cover with bordered gauze every day shift and as needed. Review of care plan dated 07/01/26 revealed no care plan regarding EBP or wound to LLE. Interview on 07/09/26 at 8:29 A.M. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure the care plan was updated to include fall interventions. This affected one (Resident #10) of 14 residents reviewed for care plans. The facility census was 44.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure palm protectors were applied as ordered. This affected one (#28) resident of one resident reviewed for splints/braces. The facility census was 44.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing was changed per professional standards of practice. Furthermore, the facility failed to ensure a PICC line was flushed per professional standards of practice. This affected one resident (#3) of one resident reviewed for PICC lines. The facility census was 44.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure insulin was labeled with an open date and failed to ensure expired insulin pens were properly disposed of. This affected three residents (#9, #14, and #27) of three residents reviewed for medication storage. The facility census was 44.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure the medical records were accurate and complete. This affected two (#15 and #46) of two residents reviewed for medical record documentation. The facility census was 44.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure open food products were dated and covered in the kitchen. This had the potential to affect all 33 residents who the facility identified to all receive food from the kitchen. The facility census was 33.

Inspectors wroteBased on the facility's water management program information, staff interview, review of the Centers for Disease Control (CDC) guidance, and review of the facility policy, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 33 residents in the facility.

Inspectors wroteBased on review of the medical record, staff interview, and facility policy review, the facility failed to complete for advanced directives for six (#2, #15, #22, #24, #28, and #30) of six residents reviewed for advanced directives and one (#22) resident reviewed hospice. The facility census was 33.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure communication was maintained between the facility and dialysis center. This affected one (Resident #2) of one reviewed for dialysis. The facility census was 33.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy, the facility failed to ensure proper hand hygiene was used during food preparation and dishwashing. This affected one resident (#11) and had the potential to affect all 36 residents residing in the facility. The facility census was 36.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to provide adequate portions of protein to residents on texture modified diets. This affected seven residents (#6, #12, #19, #23, #27, #29, and #91) identified by the facility to be on texture modified diets. The facility census was 36.

Inspectors wroteBased on medical record review, observations, resident and staff interview and policy review, the facility failed to ensure the call lights were within reach of residents. This affected one (Resident #12) of five residents reviewed for call lights. The facility census was 36.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident with a history of falling. This affected one (Resident #17) of four residents reviewed for falls. The facility census was 36.

Inspectors wroteBased on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a resident who was on a fluid restriction had fluid allowances designated to ensure staff knew how much to give the resident at meals, snacks, and medication pass. This affected one (Resident #17) of one resident reviewed on a fluid restriction. The facility census was 36.

Inspectors wroteBased on record review, review of facility's infection control logs, and staff interview, the facility failed to ensure residents were receiving the correct antibiotics. This affected one (Resident #17) of five residents reviewed for antibiotic medications. The facility census was 36.