Onpointe Transitional Care At Texas Health Arlingt

F-F600- Abuse and Neglect

Failure:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 To prevent future occurrences of potential negligence by ensuring licensed staff identify, monitor, assess, and report issues relating to residents being admitted to the facility with catheters and tubes that require Level of Harm - Immediate nursing care to prevent infection/hospitalization . jeopardy to resident health or safety DON, ADON, Nurse manger, and new Wound care nurse received in-service training on [DATE REDACTED] which consisted specifically of ensuring physician orders are in place for drains, tubes and catheters that are Residents Affected - Some inserted into the body -for treatments and for specific drainage instructions. This in-service also included recognizing symptoms of infection or change of condition(s) that might lead to infection.

On [DATE REDACTED], the DON and ADON reviewed all patients to ensure that treatment orders specific to their medical condition(s) and diagnoses are in place. No omissions were found.

If a patient had been noted with any missing treatment orders, including drain orders, the MD or NP would have been notified. If neither were available, or in an emergent situation, the DON or designee would have contacted emergency services (911).

On [DATE REDACTED] Chief Clinical Officer in-serviced Director of Nursing for [facility name] on the following.

1. Abuse/Neglect

a. Ensuring treatment orders are in place for all drains, tubes and catheters

b. Ensuring treatment orders are in place for the site of any inserted drain

c. Ensuring staff are trained in recognizing signs and symptoms of infection

d. Ensuring an effective head to toe body assessment is completed upon admission and within 48 hours

e. Ensuring clinical staff are knowledgeable in recognizing when an MD order is missing or ineffective, and how to contact the attending or surgeon for new orders

f. Ensuring a thorough clinical review/compare of the hospital discharge orders and facility admission orders occurs with each admission.

g. Ensuring a monitoring log is created with the admission criteria, treatment criteria and head to toe assessment criteria. The DON will be responsible for maintaining the log 5 times per week at a minimum for 12 weeks.

On [DATE REDACTED] initiated staff (LVN, RN, CNA) in-servicing on neglect with a completion date of [DATE REDACTED] at 5pm. Any staff who have not received in-serving by [DATE REDACTED] at 5pm will not be permitted to work until in-servicing has been completed.

Measures to be put into practice to monitor to prevent future occurrence will include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 a. Medical records/Designee will cross check progress notes/clinical admission assessments for drain orders

Level of Harm - Immediate b. Wound Care nurse will perform head to toe assessment on all new admissions within 48hrs ensuring jeopardy to resident health or appropriate treatments are obtained. safety c. Interdisciplinary Team will audit resident orders 5x weekly times 12 weeks to ensure appropriate drain Residents Affected - Some orders are entered. Any findings will be immediately corrected with further education and/or disciplinary action.

During monitoring, interviews were conducted on [DATE REDACTED] from 12:01 pm through 5:53 pm. The facility nursing staff revealed they had been trained on what to do when they received a resident without orders, a resident with any type of drains/ lines/tubes, head to toe assessment, reporting to the physician, reporting to ADON, DON, and administrator, and CNA's reporting to the nurses. The staff interviewed consisted of RN A, CNA B, LVN C, RN D, RN F, nurse manager, ADON, and new wound care nurse.

During interview and observation on [DATE REDACTED] from 02:00pm to 4:00 pm, five residents (Resident #1, #2, #3, #4, #5) had some form of line, tube or drain coming out of their bodies. Resident #2 had a PICC line, Resident #3 and Resident #4 had an indwelling catheter to drain urine from the bladder and Resident #5 had

a JP drain. All drains/lines were dated, emptied and clean, output documented. Residents stated that they had no concerns with their lines. They stated their lines/drains/tubes were emptied as needed, cleaned and new dressing applied as needed. Two residents with indwelling catheters stated that they received catheter care daily. All residents stated output had been measured, and emptied by the nurses and that site care and assessment was done every shift.

Record review of orders for the five residents on [DATE REDACTED] , reflected line/drain/tube care, management, and date to change/replace.

Record review of MAR/TAR for the five residents on [DATE REDACTED] , reflected dated inserted, dressing change dates, amount of output.

Record review of in service dated [DATE REDACTED] titled Abuse/ in connection IJ 600, reflected RNs, LVNs, MDS, ADON, and CNAs had received one on one training by DON and Infection control nurse on [DATE REDACTED]. Nursing department staff were trained regarding the following topics:

Skin assessments - weekly head to toe assessments, identify areas, who to notify, what/where to document.

Changes of condition - who to report to, things to mention, who to notify, how to document.

Wounds - notify physician, obtain orders, and document. Resident care - signs and symptoms and prognosis

Documentation on electronic healthcare system. CNAs to report any skin issues, bleeding, drain/line issues

during incontinence care and showers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview with the Administrator on [DATE REDACTED] at 05:53 PM, he sated one on one in services had been completed with nursing staff and some in services had been completed over the phone. He stated all nursing Level of Harm - Immediate staff would not be allowed to work their shift until they were in-served. jeopardy to resident health or safety While the IJ was removed on [DATE REDACTED], the facility remained out of compliance at a severity level of no actual harm that is not Immediate Jeopardy with a scope of pattern due to the facility continuing to monitor the Residents Affected - Some implementation and effectiveness of their plan of removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 676407

F-F726- Competent Nursing Staff

Failure:

To ensure nursing staff are trained relating to residents being admitted to the facility with catheters and tubes that require nursing care and preventing infection/hospitalization .

On [DATE REDACTED] DON, ADON, Medical Records Nurse, and Wound Care Nurse in-serviced licensed staff on identifying new patient treatment requirements based on their medical diagnoses and conditions. The training consisted specifically of ensuring physician orders are in place for catheters and tubes that are inserted into the body - both for a treatment and for specific drainage instructions. This in-service also included recognizing symptoms of infection or change of condition(s) that might lead to infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 On [DATE REDACTED], the DON and ADON reviewed all patients for the presence of drains and found no other patients with a drain currently resides in the facility. Assessments consisted of a head-to-toe physical assessment to Level of Harm - Immediate look for the presence of an inserted drain and visible signs or symptoms of infection. Vital signs were jeopardy to resident health or reviewed for changes that might indicate infection. No patients were noted to have any sign or symptom of a safety new infection. In addition, the medical charts of all patients were reviewed by comparing hospital discharge orders with facility admission orders and no missing treatment orders were found. Residents Affected - Some If a patient had been noted with any missing treatment orders, including drain orders, the MD or NP would have been notified. If neither were available, or in an emergent situation, the DON or designee would have contacted emergency services (911).

On [DATE REDACTED] Chief Clinical Officer [name], in-serviced Director of Nursing for [facility name and location] on the following.

2. Competent Nursing Staff

a. Ensuring treatment orders are in place for all drains, tubes, and catheters.

b. Ensuring treatment orders are in place for the site of any inserted drain.

c. Ensuring staff are trained in recognizing signs and symptoms of infection.

d. Ensuring an effective head to toe body assessment is completed upon admission and within 48 hours.

e. Ensuring clinical staff are knowledgeable in recognizing when an MD order is missing or ineffective, and how to contact the attending or surgeon for new orders.

f. Ensuring a thorough clinical review/compare of the hospital discharge orders and facility admission orders occurs with each admission.

g. Ensuring a monitoring log is created with the admission criteria, treatment criteria and head to toe assessment criteria. The DON will be responsible for maintaining the log 5 times per week at a minimum for 12 weeks.

On [DATE REDACTED] initiated staff (LVN, RN, CNA) in-servicing on competent nursing with a completion date of [DATE REDACTED] at 5pm. Any staff who have not received in-serving by [DATE REDACTED] at 5pm will not be permitted to work until in-servicing has been completed.

Measures to be put into practice to monitor to prevent future occurrence will include:

a. Medical records/Designee will cross check progress notes/clinical admission assessments for drain orders.

b. Wound Care nurse will perform head to toe assessment on all new admissions within 48hrs ensuring appropriate treatments are obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 c. Interdisciplinary Team will audit resident orders 5x weekly times 12 weeks to ensure appropriate drain orders are entered. Any findings will be immediately corrected with further education and/or disciplinary Level of Harm - Immediate action. jeopardy to resident health or safety During monitoring, interviews were conducted on [DATE REDACTED] from 12:01 pm through 5:53 pm. The facility nursing staff revealed they had been trained on what to do when they received a resident without orders, a Residents Affected - Some resident with any type of drains/ lines/tubes, head to toe assessment, reporting to the physician, reporting to ADON, DON, and administrator, and CNAs reporting to the nurses. The staff interviewed consisted of RN A, CNA B, LVN C, RN D, RN F, nurse manager, ADON, and new wound care nurse.

During interview and observation on [DATE REDACTED] from 02:00pm to 4:00 pm, five residents (Resident #1, #2, #3, #4, #5) had some form of line, tube or drain coming out of their bodies. Resident #2 had a PICC line, Resident #3 and Resident #4 had an indwelling catheter to drain urine from the bladder and Resident #5 had

a JP drain. All drains/lines were dated, emptied and clean, output documented. Residents stated that they had no concerns with their lines. They stated their lines/drains/tubes were emptied as needed, cleaned and new dressing applied as needed. Two residents with indwelling catheters stated that they received catheter care daily. All residents stated output had been measured, and emptied by the nurses and that site care and assessment was done every shift.

Record review of orders for the five residents on [DATE REDACTED], reflected line/drain/tube care, management, and date to change/replace.

Record review of MAR/TAR for the five residents on [DATE REDACTED], reflected dated inserted, dressing change dates, amount of output.

Record review of orders for the five residents [DATE REDACTED], reflected line/drain/tube care, management, and date to change/replace.

Record review of MAR/TAR for the five residents on [DATE REDACTED], reflected dated inserted, dressing change dates, amount of output.

Record review of in service dated [DATE REDACTED] titled Competent nursing/ infection control in connection IJ726, reflected RNs, LVNs, MDS, ADON, and CNAs had received one on one training by DON and Infection control nurse on [DATE REDACTED].

Nursing department staff were trained regarding the following topics:

Skin assessments - weekly head to toe assessments, identify areas, who to notify, what/where to document.

Changes of condition - who to report to, things to mention, who to notify, how to document.

Wounds - notify physician, obtain orders, and document. Resident care - signs and symptoms and prognosis

Documentation on electronic healthcare system. CNAs to report any skin issues, bleeding, drain/line issues

during incontinence care and showers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 In an interview with the Administrator on [DATE REDACTED] at 05:53 PM, he sated one on one in services had been completed with nursing staff and some of the in services had been completed over the phone. He stated all Level of Harm - Immediate nursing staff would not be allowed to work their shift until they were in-served on Competent nursing and jeopardy to resident health or infection control. safety While the IJ was removed on [DATE REDACTED], the facility remained out of compliance at a severity level of no actual Residents Affected - Some harm that is not Immediate Jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48520 jeopardy to resident health or safety Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive Residents Affected - Some person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care.

The facility failed to ensure Resident #1's stomach drain tube and drainage bag were documented on admission to the facility on [DATE REDACTED] and accurately assessed, monitored, and treated. The drain was identified on [DATE REDACTED] when family mentioned the stomach tube drainage to the physician and four days later

on [DATE REDACTED], Resident #1 required hospitalization due to infection.

The facility failed to ensure the surgeon was notified for Resident #1's missing orders for drain tube monitoring.

An Immediate Jeopardy (IJ) was identified on [DATE REDACTED]. The IJ template was provided to the facility on [DATE REDACTED] at 12:00 pm. While the IJ was removed on [DATE REDACTED], the facility remained out of compliance at a severity level of no actual harm that is not Immediate Jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

These failures could place residents at risk for a delay in treatment or diagnosis of new symptoms, a decline

in the resident's condition, the need for hospitalization or death.

Findings included:

Review of Resident #1's face sheet on [DATE REDACTED], reflected an [AGE] year-old woman admitted to the facility on [DATE REDACTED]. Her initial admitted to the facility was [DATE REDACTED]. Her diagnoses included encephalopathy (a condition of the brain that alters brain function or structure), acute duodenal ulcer with perforation (a condition in which

an ulcer has burned through the stomach wall in a segment of the intestine tract allowing gastric content to leak into the abdominal cavity) , diverticulosis of the large intestine without perforation or abscess and without bleeding (this is a condition in which small bulging pouches develop in the large intestine), kidney stones, generalized muscle weakness, elevated white blood count, irregular heart rhythm (atrial fibrillation), and need for assistance with personal care. Resident #1 was a full code directive requiring CPR if her heart stopped.

Review of Resident #1's admission MDS assessment dated [DATE REDACTED] reflected a BIMS score of 99, indicating severe cognitive impairment. MDS did not reflect any evidence of Resident #1's stomach tube or drainage bag.

Review of Resident #1's order summary from [DATE REDACTED] to [DATE REDACTED] reflected Amoxicillin oral tablet 200 mg, give 1 tablet by mouth every 12 hours for infection for 1 day . Order date [DATE REDACTED]. Acetaminophen tablet 500 MG, give 1 tablet by mouth every 6 hours as needed for pain start date [DATE REDACTED]. Acetaminophen increased to 1000 MG on [DATE REDACTED]. Acetaminophen tablet 500 MG, give 2 tablets by mouth every 6 hours as needed for pain start date [DATE REDACTED]. The acetaminophen medication did not specify if it was related to drain/abdomen. Order summary did not reflect any evidence of orders for Resident #1's stomach tube or drain bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident #1's care plan on [DATE REDACTED], reflected Resident #1's stomach tube and drain were not addressed. Level of Harm - Immediate jeopardy to resident health or Review of Resident #1's Medication/Treatment Administration Record (MAR/TAR), dated [DATE REDACTED] to [DATE REDACTED], safety reflected no evidence of orders for wound care to Resident #1's drainage tube or of any incision care treatment. Skin was noted by RN A as WNL signed off on every shift from [DATE REDACTED] to [DATE REDACTED] , however there Residents Affected - Some was no documentation of site care, dressing change, temperature to site, drainage amount and if so, how much was noted. PRN Acetaminophen 500 mg, 2 tablets by mouth as needed for pain was administered on [DATE REDACTED] in the morning, one time for pain of 4 out of 10. On [DATE REDACTED] it was administered two times, for morning pain of 5 out of 10, and afternoon pain of 4 out of 10. On [DATE REDACTED] it was administered three times for morning pain of 5 out of 10, afternoon pain of 4 out of 10, and evening pain of 4 out of 10. Facility did not provide MAR for [DATE REDACTED] to [DATE REDACTED].

Review of Resident #1's Clinical admission assessment by RN A dated [DATE REDACTED] did not reflect that Resident #1 had any type of drains or evidence of having drains on her body on the care profile for drain assessment.

Review of Resident #1's hospital discharge records dated [DATE REDACTED] at 2:24 pm, reflected continuation of medications acetaminophen 500 mg tablet (for pain not specific), alum-mag hydroxide-simeth [DATE REDACTED] mg/5 ml suspension (gas relief medication), artificial tears drop (for dry eyes), fluconazole 150 mg tablet, heparin 5, 000 units/ml solution (blood thinner), labetalol 5 mg/ml solution (for blood pressure medication), melatonin 3 mg tablet (sleep aide), metoprolol tartrate 50 mg tablet(for blood pressure medication),, pantoprazole 40 mg tablet (for reflux/heart burn) and Amoxicillin oral tablet 200 mg every 12 hours for infection for 1 day . The discharge record reflected to schedule an appointment with family practice as soon as possible post hospital discharge follow up appointment. No orders for the drainage tube were noted.

Review of Resident #1's progress notes by RN A dated [DATE REDACTED] at 07:30 AM, revealed Resident #1 skin assessment as follows: incision at the RUQ with a draining tube, the dressing is clean dry and intact, PICC line on the arm was taken off on ,d+[DATE REDACTED] dressing upper arm. Oxygen is nasal canula 2L, LBM today [DATE REDACTED]. No progress notes related to drainage tube were recorded during skin checks, incontinent care, or shower/bed bath between [DATE REDACTED] to [DATE REDACTED] at 4:20 pm.

Review of Resident #1's progress notes by RN D dated [DATE REDACTED] at 06:31 PM, reflected a change in condition for uncontrolled pain. An assessment of the abdomen revealed abdominal pain. Primary care provider recommendation was to send Resident #1 to the emergency room . Progress notes on [DATE REDACTED] at 06:31 pm was the first progress note to mention anything related to the drainage tube.

Review of Resident #1's progress notes by RN D dated [DATE REDACTED] at 7:01 PM, reflected as follows Patient [Resident #1] had a change in condition. Purulent (pus/milky looking liquid substance) discharge observed from surgical drain site. Drainage bag doesn't seem to be working, right, and no drainage has been noted since patient's admission into facility. Surgical site warm to touch. Wound nurse examined surgical site, took pictures, and changed dressing. [physician] notified and pictures shared with him. [physician] requests to send patient downstairs to ER for eval[evaluation]. Required documentation prepared. ER nurse is called and notified of patient's condition. Patient is assigned to Room [#] in ER. Vitals taken and within normal range, BP ,d+[DATE REDACTED], Temp 98.8, HR 67 and RR 20. Patient's [family] present. Patient is taken downstairs accompanied by [family]. Nurse [name] receives patient and receives report from me.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Review of Resident #1's hospital record dated [DATE REDACTED] through [DATE REDACTED], reflected the following summary:

Level of Harm - Immediate Resident #1 was evaluated by a surgeon and an Infectious Diseases doctor, and they noted diagnosis as jeopardy to resident health or Post operation infection of the intra-abdominal abscess IR drain. Resident #1 presented to ER from facility safety with purulent discharge from the IR drain. Surgeon replaced the infected IR drain and a new drain was placed. Resident #1 still complained of abdominal pain then a KUB was done which showed possible Residents Affected - Some retraction of drain. The CT revealed that the drain had migrated. Resident #1's drain was repositioned. Cultures showed Klebsiella (a bacteria that is mostly spread from person to person via contact. The bacteria spreads by contamination in the environment, and it is the most common health care associated infection). Resident was started on intravenous antibiotics Zosyn and Diflucan and then she was e started cefepime flagyl and fluconazole as per Infectious Diseases doctor recommendations. It was recommended that the drain was flushed with saline 10 cc every 12 hours and that a repeat CT scan would to be done again in , d+[DATE REDACTED] weeks . Resident #1 was discharged back to the facility in stable condition on [DATE REDACTED] and a recommended order to follow up with the surgeon.

In an interview with Resident #1 and family on [DATE REDACTED] at 11:44 AM, family stated that he was frustrated with

the first surgeon because Resident #1 was admitted to facility on [DATE REDACTED] without him getting any discharge paperwork from the hospital. He stated that the ADON obtained it for him later. Family stated that he mentioned the drain to the facility physician on [DATE REDACTED] stating that the drain was not putting out any drainage. Family stated that the facility physician told him that he would contact the surgeon. Family stated that the facility physician did not even look at the drain. He stated that he did not see any nurses observed drain site or check the drain while he was in the facility. Family stated that on [DATE REDACTED] the facility physician came to see Resident #1 and he asked him about the drain not putting out anything and what the surgeon had said to do next. Family stated that the facility physician stated that he had left a voicemail for the surgeon, and he had not heard from him. On [DATE REDACTED] as CNA B was cleaning resident, he notified family that

he noticed oozing from the dressing of the drain. Nurse was notified, then ADON came to see resident and facility physician was notified and Resident #1 was sent to the ER.

In a phone interview with RN A on [DATE REDACTED] at 7:52 PM, she stated that she admitted Resident #1 to the facility and completed Resident #1's admission on [DATE REDACTED]. She stated that she did not ask about the drain

during report because she assumed that Resident #1 already had an order since she was transferring from

the hospital attached to the facility. She stated that RN F on day shift had gotten report from the hospital. RN

A stated it was her responsibility to notify the facility physician to obtain orders or called the hospital nurse that gave them report for clarification on monitoring Resident #1's drain. She stated the facility process was to notify the facility physician or on call physician if they had an admission without orders. She stated that

she did not follow up to see if orders had been obtained for Resident #1 the next day [DATE REDACTED] because Resident #1 had been moved from her assignment due to relocation to another room. She sated the risk was infection for not knowing how to care for Resident #1's drain. She stated that it was neglect that she did not obtain orders to care for Resident #1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview with CNA B on [DATE REDACTED] at 1:30 PM, he stated that he had been assigned Resident #1's hallway and as he was giving her incontinent care on [DATE REDACTED] he noticed that Resident #1's dressing was Level of Harm - Immediate leaking . He stated that he was aware that Resident #1 had come to facility after a surgical procedure but as jeopardy to resident health or a CNA, he was not allowed to access the drain or empty the drainage bag. He stated that he notified family safety because family was in the room and that family was very involved with resident. CNA B stated that family went out of the room and called RN D to the bedside. He stated neglect was not going to a resident's room Residents Affected - Some when they called, not cleaning a resident when they are soiled and not reporting to the nurse if a resident needs something.

In an interview with LVN C on [DATE REDACTED] at 5:30 PM, she stated when Resident #1 was moved from RN A's hallway, she took over care for Resident #1 the next day [DATE REDACTED]. LVN C stated the family informed her of the drain and she assessed it. She stated Resident #1's skin around the dressing was intact and she did not see anything unusual about her skin or drain. She stated she knew Resident #1 did not have orders for drain care and management. She stated all she did was assessed the skin around the dressing. She stated that

she could have reached out to the physician for orders. She stated the risk to Resident #1 was neglect for not having orders to care for her drain.

In an interview with RN F on [DATE REDACTED] at 4:15 PM, she stated she got report from the hospital for Resident #1 and she gave the report to RN A. She stated she did not admit Resident #1. She stated neglect was not addressing a resident's need, not taking care of them as you should.

In an interview with ADON on [DATE REDACTED] at 03:11 PM, she stated RN A should have gotten an order set for drain care. She stated that the process was to get report from the hospital, then if resident did not have orders, to notify the physician, her, the wound nurse, and the DON. She stated she was not notified of Resident #1's drain until [DATE REDACTED] when she made rounds with the facility physician, and he assessed the drain. She stated the physician should have put orders to maintain the drain. ADON stated on [DATE REDACTED], RN E notified her of Resident #1's drain leaking. She stated upon assessment it was warm to touch and that she worked closely with Resident #1's family to send Resident #1 to the ER after communicating with the facility physician. She stated orders drive care and not having orders placed Resident #1 at risk of not getting drain care and infection. She stated that she started to in-service nurses on drain management and infection control after incident with Resident #1 on [DATE REDACTED]. She stated she did not like the word neglect, but she could see how not obtaining orders can be considered neglectful.

Attempts to interview surgeon and or nurse practitioner was unsuccessful on [DATE REDACTED] at 2:33PM.

In an interview with DON on [DATE REDACTED] at 4:52 PM, she stated that if there are no orders at admission to the facility, she expected nurses to reach out to the physician. She stated the wound care nurse should have seen Resident #1 as she was a new admission to determine the type of drain that Resident #1 had and to request additional care orders. She stated all findings during assessment should be documented in resident's care clinical documentation. DON stated that the wound care nurse at the time of Resident #1's admission [[DATE REDACTED]], was no longer with the facility because he missed a lot of important details such as for Resident #1's drain. She stated that orders drive care and Resident #1 was placed at a risk for not getting drain management, which caused drain issues and possible infection. She stated the ADON started an in-service for nursing staff the same day Resident #1 was sent to hospital on [[DATE REDACTED]]. DON said she could not say if not obtaining drain care orders for Resident #1 was neglect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 676407 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676407 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Purehealth Transitional Care at Thr Arlington 800 W. Randol Mill Road, 6th Floor Arlington, TX 76012

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In an interview with the administrator on [DATE REDACTED] at 05:05 PM, he stated all residents that are admitted to the facility are considered complex residents. He stated he expected nursing staff to communicate effectively Level of Harm - Immediate and to obtain orders from the physician as needed. He stated the expectation was that the admitting nurse jeopardy to resident health or would complete an initial skin assessment and then wound care nurse would follow up and complete a skin safety assessment on all new admissions within 48 hours unless the admission was on the weekend. The administrator did not state the risk to Resident #1. He stated the facility admitted 60 to 80 residents each Residents Affected - Some month and he did not know each one's care. The administrator stated wound care nurse was terminated due to failure to report and other issues.

Review of facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention program, revision date [DATE REDACTED], reflected, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .

Interview with DON on [DATE REDACTED] at 08:24 AM, she stated the facility had dropped the ball on Resident #1's lack of care orders for her drain. She stated an IDT meeting was held on [DATE REDACTED] to identify where they went wrong. She stated they started a plan of correction.

On [DATE REDACTED] at 12:00 PM the Administrator, the DON, and the nurse manager were informed of an Immediate Jeopardy existed and a copy of the IJ template was provided.

In an interview with the facility physician on [DATE REDACTED] at 01:52 PM, he stated that he was aware that Resident #1 had a drain. He stated that it was the surgeon's responsibility to place care orders for the drain. He said usually all surgical admissions with any drains, lines or tubes had orders from the surgeon. He stated that Resident #1's family asked him to remove the drain because there was no output. The facility physician stated that it was common sense and a nurse best practice to clean the skin around the incision, to monitor output and to report change. He stated it was common sense for nurses to reach out to surgeons for orders so that they can know what to monitor, fluid amount for output and any interventions needed. He stated there was a risk for infection if not monitored.

In a phone interview with RN D on [DATE REDACTED] at 2:04 PM, she stated that she had been employed at the facility for five months. She stated she cleaned around the insertion site, and she changed the dressing because it was soiled after CNA B notified her of the leak. She stated she notified the wound care nurse who came and took pictures and sent to the physician. She stated Resident #1 was neglected because no one got orders to care for her drain. She stated the risk for not providing care to the surgical site was infection. She stated neglect was not providing care that is required to Resident #1.

Plan of Removal was accepted on [DATE REDACTED] at 4:13 PM.

Plan of Removal: [facility name]

Date: [DATE REDACTED]

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