Town Hall Estates - Arlington, Inc.

In the surveyor’s words

From the most serious findings on record at Town Hall Estates - Arlington, Inc., in the surveyor’s own words.

• Immediate jeopardy, patternF686Jul 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Nov 20, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF635Jul 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Jul 29, 2022

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. On 07/23/22 CNA A failed to comply with the facility's no cell phone use policy and conversed on her personal cell phone while preparing Resident #1 for an assisted transfer using a mechanical lift. Resident #1 fell from the lift resulting in a laceration to the right forehead that required 5 sutures to close, a fractured right upper arm and subarachnoid hemorrhage (bleeding within the subarachnoid space located between the brain and the tissue covering the brain). […]

• Actual harm, isolatedF684Dec 27, 2021

  Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, based on the comprehensive person-centered care plan, and the residents' choices for one of five residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 did not suffer injury and extreme back pain during her physical therapy treatment on 09-02-21. Following the physical therapy treatment, the resident was unable to continue physical therapy for the remainder of her stay at the facility due to back pain. […]