ARLINGTON, WA - A February 2025 federal inspection at Arlington Health and Rehabilitation revealed widespread deficiencies in medication management, infection control, food service, and care coordination that placed residents at risk for adverse health outcomes.
Medication Storage and Handling Failures Discovered
Inspectors documented critical lapses in pharmaceutical safety protocols during their survey of the 620 South Hazel Street facility. On February 3, 2025, surveyors discovered expired medications stored in the facility's refrigerator, including three vials of lorazepam—an anti-anxiety medication—that had expired in October 2024, four months prior to the inspection.
Additionally, inspectors found a bag labeled "Promethegan" with concerning documentation issues. The original 2023 expiration date printed on the label had been crossed out and replaced with a handwritten date of April 2025. When questioned, nursing staff stated the medication had come from the emergency kit but could not identify who had altered the expiration date.
The inspection also revealed improper storage of temperature-sensitive medications. An open bottle of Acidophilus, a probiotic supplement with clear instructions to "refrigerate after opening," was found stored at room temperature in a medication cart on the Medicare Hall.
Proper medication storage represents a fundamental patient safety requirement. Probiotics like Acidophilus contain live bacterial cultures that lose potency when exposed to inappropriate temperatures, rendering them ineffective for residents who depend on them for digestive health. Expired medications can undergo chemical changes that reduce effectiveness or, in some cases, produce harmful degradation products. The use of expired lorazepam is particularly concerning given this medication's role in managing anxiety and preventing seizures in certain populations.
According to the inspection report, a Licensed Practical Nurse acknowledged that all nursing staff should routinely check medication carts for expired products "when time allows." However, the presence of medications expired for four months suggests this practice was not occurring consistently.
Infection Control Breaches During Active Outbreak
Perhaps most alarming, inspectors documented multiple infection prevention failures while the facility was experiencing an active gastrointestinal virus outbreak. Staff compliance with Enhanced Barrier Precautions—specialized infection control measures for residents with wounds, medical devices, or drug-resistant organisms—was inadequate across three of four hallways.
On January 31, 2025, inspectors observed a Licensed Practical Nurse performing wound care on Resident 13, who had both a multi-drug-resistant bacteria in their lungs and a foot wound. The nurse wore only a mask and gloves—no gown—despite facility policy requiring full personal protective equipment during high-contact care activities.
More concerning was the technique used during the procedure. The nurse used the same pair of gloves while treating three separate wounds on different areas of the resident's feet, reaching repeatedly into clean supply packages with contaminated gloves. The overbed table used for the procedure was not covered, and wound care supplies were placed directly next to the resident's television remote and drinking water container. When questioned, the nurse stated they believed glove changes were only necessary "if gloves were soiled or if they go from one area of the body to another, such as when they go from the buttocks to another area of the body."
This represents a fundamental misunderstanding of aseptic technique. Standard infection control protocols require healthcare workers to change gloves between different body sites—even on the same patient—to prevent cross-contamination. Using contaminated gloves to handle clean supplies creates a chain of transmission that can spread bacteria to multiple residents.
The inspection documented additional infection control lapses, including staff failing to perform hand hygiene after removing gloves, inconsistent use of gowns during personal care, and improper catheter bag placement. One resident's urinary catheter collection bag was repeatedly observed touching the floor and lying inside a trash bin on top of garbage—violations of basic catheter care principles designed to prevent urinary tract infections.
Urinary tract infections represent one of the most common healthcare-associated infections in nursing homes. When catheter bags contact contaminated surfaces like floors or garbage, bacteria can travel up the drainage tubing into the bladder, causing painful infections that may progress to life-threatening sepsis in vulnerable elderly residents.
Food Safety and Temperature Control Problems
The inspection revealed systematic failures in food safety practices. On January 31, 2025, inspectors observed a full cart of breakfast trays sitting in a hallway at 8:47 AM, with none yet served to residents. When a nursing aide finally began distributing trays at 8:52 AM, the Dietary Manager checked the temperature of oatmeal on one of the remaining trays, finding it measured only 124 degrees Fahrenheit—well below the facility's own policy requiring hot cereals to be maintained at 165 degrees or above.
The facility's posted dining schedule indicated residents who eat in their rooms should receive meals between 7:45 AM and 8:45 AM. However, staffing shortages on South Hall meant trays sat unserved for extended periods, allowing hot foods to cool below safe and palatable temperatures.
Temperature control matters for both food safety and nutritional intake. Hot foods that cool below recommended temperatures may enter the "danger zone" where bacterial growth accelerates. Equally important, unappetizing food temperatures contribute to reduced food consumption among elderly residents, many of whom already face challenges maintaining adequate nutrition. During the Resident Council meeting on January 30, 2025, residents reported that "food served was consistently cold and late and was especially bad on the weekends."
Food storage practices also raised concerns. Inspectors found multiple unlabeled and undated food items in kitchen refrigerators, including opened cottage cheese, freezer jam, and applesauce. Professional food safety standards require all opened items to be dated to ensure timely use before spoilage occurs. In the nourishment refrigerator, inspectors discovered a medical supplement dated August 4 (presumably of the previous year), opened milk with no date, and opened eggnog with no date.
The outdoor refrigerator contained four cucumbers wrapped in plastic with "visible black circles on them" that were "mushy to touch"—clear signs of spoilage. The Dietary Manager acknowledged the cucumbers were spoiled and stated they had been delivered approximately five days earlier.
Hospice Care Coordination Breakdown
The facility failed to maintain adequate coordination with hospice services for Resident 22, who was admitted to hospice care on November 13, 2024. Despite a written agreement requiring the facility to coordinate with hospice in developing plans of care and to abide by those plans, inspectors found no hospice plan of care in the resident's electronic health record.
The absence of an integrated care plan became apparent when the resident experienced increasing confusion and agitation in late December 2024. Hospice nursing notes documented multiple calls from evening staff and the resident's daughter coming to the facility to help calm them. Progress notes showed the resident "had been anxious over the last few days with behaviors of self-propelling up/down halls, and in and out of rooms, bumping into objects and almost running over other residents' toes."
Effective hospice care requires seamless communication between the nursing facility and hospice provider. When care plans are not properly integrated, staff may be unaware of specific interventions for managing symptoms like terminal restlessness or anxiety. This can result in unnecessary distress for dying residents and their families.
When questioned on February 5, 2025, nursing staff stated they would "try to find the care plan." A Licensed Practical Nurse later provided a copy of the hospice care plan stamped with that day's date—February 5, 2025—and stated "they did not know why the hospice care plan was not in Resident 22's EMR."
Additional Issues Identified
Beyond these major violations, inspectors documented several other deficiencies:
Enhanced Barrier Precaution signage inconsistencies: Staff provided conflicting explanations about what blue rectangular markers on door frames indicated, with responses ranging from "two-person assist required" to "fall risk" to "resident on precautions."
Missing precaution indicators: Resident 13, who had physician orders for Enhanced Barrier Precautions due to respiratory MRSA (methicillin-resistant Staphylococcus aureus), had no visible signs indicating precautions were in effect. The Infection Preventionist acknowledged this represented "a miscommunication between them and the Resident Care Manager."
Hand hygiene failures: A housekeeper was observed removing dirty gloves and applying clean gloves without performing hand hygiene between glove changes, stating "their usual practice was not to perform hand hygiene between gloves change."
Enteric precaution violations: A Registered Nurse exiting a room under enteric contact precautions used hand sanitizer instead of washing with soap and water as required by posted signage, and failed to disinfect an inhaler before removing it from the room, contaminating clean gown supplies in the process.
The February 2025 inspection identified systemic failures across multiple departments at Arlington Health and Rehabilitation, indicating breakdowns in staff training, policy implementation, and quality oversight. These deficiencies collectively created an environment where residents faced heightened risks for medication errors, healthcare-associated infections, foodborne illness, and inadequate end-of-life care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arlington Health and Rehabilitation from 2025-02-05 including all violations, facility responses, and corrective action plans.
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