Arlington Gardens Care Center

In the surveyor’s words

From the most serious findings on record at Arlington Gardens Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF627Oct 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF684Jan 8, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF755Jan 8, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF759Jan 8, 2026

  Based 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). […]

• No harm, potential for more than minimal, patternF880Jan 8, 2026

  Based 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. […]