Serenity Spring Senior Living at Arlington

In the surveyor’s words

From the most serious findings on record at Serenity Spring Senior Living at Arlington, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF868Jul 9, 2026

  Review 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.Findings include:Review of QAPI sign-in sheets revealed the medical director did not attend QAPI on 11/25, 12/25, 01/26, 02/26, and 03/26. The facility was unable to locate the sign-in sheets for 01/26 and 03/26.Interview on 07/09/26 at 11:46 A.M. with the Administrator revealed he provided all the QAPI sign-in sheets that he was able to locate. Interview on 07/09/26 at 1:14 P.M. […]

• No harm, potential for more than minimal, widespreadF880Jul 9, 2026

  Based 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). […]

• No harm, potential for more than minimal, widespreadF881Jul 9, 2026

  Based 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. Findings include:Review of the facility's infection control binder revealed from January 2026 through June 2026 the facility did not conduct ongoing review for antibiotic stewardship. Interview on 07/08/26 at 4:19 P.M. with Nursing Manager (NM) #121 who was the facility's Infection Preventionist (IP) revealed she was hired into the position of IP in May of 2026. […]

• No harm, potential for more than minimal, widespreadF947Jul 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based 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. Findings include: Observation on 04/15/24 at 8:20 A.M. of the kitchen revealed in the dry storage area, five bags of open pasta were not dated. In the walk-in refrigerator, two trays of mandarin oranges were not covered or dated and two bags of mozzarella cheese open with no date. In the walk-in freezer, one bag of Salisbury steak open with no date. […]