Arlington Health & Rehab: Resident Death - WA
ARLINGTON, WA - Arlington Health and Rehabilitation faced an immediate jeopardy citation after state inspectors found nursing staff failed to properly assess and monitor a resident experiencing severe abdominal pain over multiple days, ultimately leading to the resident's death from septic shock.
Failure to Monitor Deteriorating Resident
The August 2024 inspection revealed that Resident 1, who had a history of atrial fibrillation, diabetes, and stroke, experienced escalating abdominal discomfort from July 22-24, 2024, but nursing staff failed to conduct proper assessments or timely physician notification during the critical period.
According to inspection records, the resident first reported abdominal discomfort on July 22 at 9:45 PM and received antacid medication twice without relief. The discomfort continued through July 23, with nursing notes documenting that the resident had only small bowel movements over 48 hours and "needed to be assessed" - yet no assessment was documented.
The situation deteriorated significantly during the overnight shift of July 23-24. A nursing assistant reported that the resident was "calling out all shift, placing their call light on as soon as they would leave the room." The resident's continuous crying and calling for help became so disruptive that staff moved the roommate to another room down the hall.
Despite these clear signs of distress, the licensed practical nurse on duty failed to conduct vital sign checks or physical assessments. The nurse only notified the physician by fax at 4:19 AM on July 24, approximately two hours after documenting that the resident was "calling out, crying and disruptive" and that staff were "unable to relieve discomfort with antacids."
Critical Medical Deterioration Goes Undetected
The inspection revealed that vital signs, a fundamental monitoring tool in healthcare, were not checked for over 14 hours during the resident's acute decline. Records show the last documented vital signs were taken at 3:52 PM on July 23, with no additional monitoring until 6:00 AM on July 24 when the day shift discovered the resident in severe distress.
When the morning nursing assistant arrived for the 6:00 AM shift, they found the resident's door closed - unusual for this particular resident who preferred their door open. The room was cold with an open window, and the resident had no covers with bare legs exposed. Most critically, the call light was not within the resident's reach.
The nursing assistant found the resident covered in dark brown, coffee-colored vomit with discolored lips and very cold skin. The resident's oxygen saturation had dropped to 85% from a baseline of 96%, and they were experiencing shortness of breath with decreased lung sounds on both sides.
"The resident was saying help, help," the nursing assistant reported during interviews. "They were not making sense, and this was not Resident 1's baseline, so they ran to get a nurse."
Systemic Communication Breakdowns
The inspection uncovered significant failures in the facility's communication protocols. The overnight licensed practical nurse acknowledged during interviews that they "should have called the physician earlier as the abdominal discomfort had been occurring for a couple of days" and admitted they "did not check on the resident after they shut the door to the room" between 5:00-5:30 AM.
Even more concerning, the day shift registered nurse receiving report was unaware of the resident's multi-day abdominal pain and restlessness until after the resident was sent to the hospital. This communication breakdown meant critical information about the resident's deteriorating condition was not properly transferred between shifts.
The facility's own nursing manager confirmed that staff should have completed vital sign assessments and head-to-toe physical examinations whenever a resident experienced a change in condition. The Director of Nursing Services stated their expectation was that "the physician was called for any urgent matter or change in condition" and that licensed staff should "assess and monitor the resident continuously."
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ARLINGTON HEALTH AND REHABILITATION in ARLINGTON, WA was cited for violations during a health inspection on August 23, 2024.
According to inspection records, the resident first reported abdominal discomfort on July 22 at 9:45 PM and received antacid medication twice without relief.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.