Town Hall Estates - Arlington, Inc.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control. CNA A failed to appropriately change gloves, perform hand hygiene, and provide a clean brief while providing incontinence care to Resident #1 on 06/24/26. This failure could place residents at risk for cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents. The facility failed to provide Resident #1, who had dementia, with adequate supervision to prevent her from eloping from the facility on 11/03/25. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 11/03/25 and ended on 11/03/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of harm, severe injury, and possible death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of five residents (Resident #49) reviewed for pressure ulcers. The facility staff failed to notify the Wound Care Physician of Resident #49's Stage 2 pressure ulcer on his coccyx upon admission. Resident #49 was not provided with wound care treatment from 06/02/25 - 06/25/25 which resulted in resident's pressure ulcer worsening from a Stage 2 to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were physician orders for a resident's immediate care at the time the resident was admitted for 1 of 5 (Resident #49) reviewed for admission orders. The facility failed to obtain physician orders for Resident #49's immediate care when he admitted to the facility on [DATE] with a Stage 2 pressure ulcer on his coccyx, which resulted in the resident not receiving physician-ordered wound treatment from 06/02/25-06/24/25 and the Stage 2 pressure ulcer worsening to a Stage 4. An IJ was identified on 07/02/25. The IJ template was provided to the facility on [DATE] at 4:10 PM. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment for 1 resident (Resident #50) of 6 residents reviewed for informed consents. The facility failed to ensure Resident #50 was informed of the risks and benefits prior to being administered antipsychotic medications. This failure could place the residents at risk of receiving medications with side effects they do not wish.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one (Residents #5) of three residents reviewed for dental services. The facility failed to follow up and schedule an appointment for resident to be seen by dentist so that she could receive dentures. This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. in the facility's only kitchen. 1. The facility failed to ensure the refrigerator was maintained in a sanitary manner free from dark substances. 2. The facility failed to ensure food items stored in the freezer were properly discarded. This failure could place all residents at risk for food contamination and food borne illness.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #50) of 7 residents observed for infection control. Staff failed to use the appropriate PPE when providing care for Resident #50 who was on EBP. This failure could place resident at risk of being infected with germs from another resident. Record review of Resident #50's undated admission Record reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the leg with surgical repair, dementia, and kidney failure. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 1 of 21 residents (Residents #48) reviewed for environment. The facility failed to ensure Residents #48's bed curtain was free from a dried brown substance. This failure could affect any resident and place them at risk for not having a sanitary homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #61) reviewed for enteral nutrition. The facility failed to follow Resident #61's physician's orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection for 1 resident (Resident #1) of 3 observed for infection control. RN A failed to perform hand hygiene and change gloves during wound care for Resident #1. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 2 of 20 residents (Residents #2 and #27) reviewed for advanced directives. The facility failed to ensure Resident #2's and Resident #27's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, mental, and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 5 residents (Residents #27, #39, and #52) reviewed for care plans. 1. The facility failed to create a care plan addressing Resident #27's Apixaban Oral Tablet 2.5 mg. 2. The facility failed to create a care plan addressing Resident #39's Foley catheter. 3. The facility failed to create a care plan addressing Resident #52's Mirtazapine Oral Tablet 15 mg, Donepezil Hydrochloride Oral Tablet 10 mg, and Seroquel Oral Tablet 25 mg (Quetiapine Fumarate). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #2) reviewed for oxygen. 1. The facility failed to have physician orders for Resident #2's oxygen use. 2. The facility failed to ensure Resident #2's humidifier and nasal cannula was changed out on a weekly basis. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on two of four medication carts (Hall C) and (Hall D) and 2 of 6 (Resident #46 and #47) reviewed for pharmacy services. The facility failed to ensure the Hall C and Hall D nurses medication carts contained accurate narcotic logs for Residents #46 and #47. LVN B and LVN C failed to document the administration of narcotic medications in a correct and timely manner. These failures could place residents at risk for medication error, drug diversion, and delay in medication administration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable when applicable for 1 of 3 medication carts (Hall C medication cart) and failed to ensured all drugs and biologicals were stored securely for 1 of 5 residents (Resident #2) observed for medication storage. 1. The facility failed to ensure the medication cart for Hall C did not have the following expired medication: [...]

Inspectors wroteBased on observation, intervies, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure sanitary practices were maintained in the kitchen as the dish machine was not performing at the optimal sanitation rate due to having no chlorine and the test strips being used were both expired and the wrong type. These failures could place resident who ate from the kitchen at risk for cross-contamination and food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure there were physician orders for 2 of 15 residents (Residents #39 and #57) reviewed for physician orders. 1. The facility failed to obtain physician orders for Resident #57 gastrostomy tube flushes between medications. 2. The facility failed to obtain physician orders for Resident #39's urinary catheter, to include the size of the catheter to be used. These failures could place residents at risk of not receiving the appropriate care as ordered by the physician.

Inspectors wroteBased on observation, 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 proper incontinent care for 1 of 5 residents (Resident #26) for activities of daily living care. The facility failed to provide proper incontinence care to Residents #26 without using multiple briefs every 2 hours and as needed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of three staff (LVN A) which resulted in an 8.57% medication error rate after 35 opportunities with 3 errors for 1 of 3 residents (Resident #57) reviewed for medications. LVN A failed to flush Resident #57's gastrostomy tube with prescribed amount of water before, between, and after medications, when he administered medication. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response and put residents who received medications via gastrostomy tube at risk for gastronomy tube blockage and medication interaction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause 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, for two (Residents #1 and #2) of five residents reviewed for abuse and neglect. The facility failed to report a resident-to-resident altercation that occurred on 03/27/24 between Residents #1 and #2 to the State Survey Agency within 2 hours of being notified. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 out of 2 meals (the lunch meal on 03/08/24) reviewed for food and nutrition services. The facility failed to ensure residents on a pureed diet were served pureed bread during the lunch meal on 03/08/24. This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one (Residents #3) of four residents reviewed for resident rights. The facility did not ensure the Activity Director treated residents with dignity and respect by referring to Resident #3 as a feeder. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider for 1 (Resident #1) of 4 residents reviewed for discharge requirements. The facility failed to provide Resident #1's family with discharge instructions. This failure could place residents at risk of a disruption of the continuum of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Residents #3) reviewed for clinical records. The facility failed to ensure staff accurately documented on Resident #3's February 2024 MAR that she received her medications. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 (Treatment cart #1) of 5 medication/treatment carts reviewed for medication storage in that: Treatment cart # 1 was left unattended and unlocked. This failure could allow residents, unsupervised access to prescription and over-the-counter medications.

Inspectors wroteBased on interview and record review, the facility failed to obtain from hospice the physician recertification of the terminal illness for 1 (Resident #1) of 1 resident reviewed for hospice records. The facility failed to obtain the order for hospice services and the recertification of terminal illness for Resident #1. These failures could place residents at risk for services and treatments not being coordinated.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 residents reviewed for comprehensive care plans. Residents #1's care plan failed to address the services and interventions that would be provided by the resident's hospice agency. This failure could affect the residents who received hospice services and could result in services and treatments not being coordinated.

Inspectors wroteBased on interview and record review, the facility failed to conduct a performance review of nurse aides at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 3 of 3 CNAs (CNA D, CNA E, and CNA F) reviewed for performance reviews. The facility failed to conduct performance reviews at least every 12 months for CNAs D, E, and F. This deficient practice could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their identified needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for one (lunch meal) of one meal services reviewed. - The facility failed to ensure the pureed lunch meal was prepared in a manner to conserve nutrition, flavor, and palatability. The cook did not use a standardized recipe to prepare the pureed food items. This failure placed all residents on puree diet at risk for an imbalance in nutritive status, change of appetite, and unwanted weight loss or weight gain.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 10 (Residents #3, #8, #9, #199, #200, #202, #204, #29, #37, #150) of 17 residents reviewed for infection control. The facility failed to ensure LVN A and MA C sanitized blood pressure cuffs between uses on Residents #3, #8, #9, #199, #200, #202, #204, #29, #37 and #150. The facility failed to ensure MA C performed hand hygiene after touching her hair and before administering medicaions. This failure could place residents at risk of infectious disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #34) of 14 residents reviewed for privacy and confidentiality. The facility failed to ensure the privacy and confidentiality of Resident #34's medication orders. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy and confidentiality.