Arlington Heights Health And Rehabilitation Center

F-F600 Failure to Prevent Abuse and Neglect

Interventions:

Resident #1 was immediately placed on 1:1 supervision on 2.11.25 with facility staff.

Resident #1 discharged to alternate facility with guardians' approval 2.11.25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 455819 Department of Health & Human Services Printed: 09/08/2025 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 455819 B. Wing 02/15/2025

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

Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107

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 0600 Resident #1's baby doll with the plastic heads were immediately removed from Resident #1's possession and from resident #1's room on 2.11.25 by regional compliance nurse. Level of Harm - Immediate jeopardy to resident health or Resident's #1's care plan was reviewed by Regional Compliance Nurse for appropriate interventions to safety prevent resident and staff altercations on 2.11.25.

Residents Affected - Some Resident #1's care plan was updated by the Regional Compliance Nurse to reflect additional interventions of 1:1 supervision and removal of baby dolls with hard plastic pieces on 2.11.25.

IDT team will schedule a care plan meeting with Responsible Party, Physician, and Resident to review and evaluate interventions to prevent repeated altercations with staff and residents starting 2.11.25.

The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics. Completed 2.11.25

o Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented to prevent abuse.

o Behavior Management Policy- Managing behaviors and intervening appropriately.

The Medical Director was notified on 2.11.25 of the immediate jeopardy.

An ADHOC QAPI was held with the IDT Team on 2.11.25 to discuss the immediate jeopardy and plan of removal.

In-services

All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON to prevent resident to resident abuse and ensure appropriate response to aggressive behaviors. In-servicing initiated on 2.11.25 and will be completed by 2.12.25. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to starting their shift.

o Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented.

o Behavior Management Policy- Managing behaviors and intervening appropriately.

Monitoring of the facility's Plan of Removal included the following:

Observation on 02/12/25 at 10:04 AM revealed Resident #1 was no longer at the facility and had been discharged to another nursing facility.

Record review of Resident #1's progress notes dated 02/11/25 documented by LVN C reflected the following

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 455819 Department of Health & Human Services Printed: 09/08/2025 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 455819 B. Wing 02/15/2025

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

Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107

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 0600 Resident transferred to sister [facility] due to behaviors. Vitals within normal limits, medication and belongings sent with her. Guardian notified of transfer Level of Harm - Immediate jeopardy to resident health or Record review of the facility's inservices titled Abuse/Neglect dated 02/11/25 reflected all facility staff were safety educated on the different types of abuse, abuse prevention and ensuring interventions were implemented to prevent abuse, and managing behaviors and intervening appropriately. If staff are to witness resident to Residents Affected - Some resident abuse, they are to immediately intervene, ensure the residents are safe and report the incident to

the Administrator. To prevent abuse, staff are to redirect residents away from aggressive or agitated behaviors and watch for signs of aggression.

Interviews on 02/12/25 at 1:02 PM to 02/13/25 at 2:35 PM from staff from various shifts were the Administrator, DON ADON P, Weekend Supervisor, Social Worker, Transportation, BOM , Medical Records, Dietary Manager, PTA, OT, LVN A, LVN C, Housekeeper D, LVN E, CNA F, LVN G, MA I, MDS Nurse K, MDS Nurse L, CNA N, CNA O, MA Q, CNA R, Housekeeper T, Housekeeper U, CNA V, [NAME] W, [NAME] X, MA, Z, CNA AA, and CNA BB. All staff were able to identify the following:

- The different types of abuse.

- What to do if they witness resident to resident abuse.

- What signs to watch for in residents to prevent resident to resident abuse/behaviors

- Who to report any incidents of abuse

- All staff stated there were no other residents they were aware of that were having consistent physical altercations in the facility.

The Administrator was notified on 02/13/25 at 3:30 PM, the Immediate Jeopardy was removed. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm 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 9 of 11 455819 Department of Health & Human Services Printed: 09/08/2025 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 455819 B. Wing 02/15/2025

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

Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107

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 0691 Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43791

Residents Affected - Few Based on interview and record review, the facility failed to ensure residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #5) reviewed for ostomy care.

The facility failed to assist Resident #5 with colostomy care resulting in her colostomy leaking.

This failure could place the resident at risk of skin irritation and breakdown from exposure to fecal matter.

Findings included:

Record review of Resident #5's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses which included stroke affecting the rights side of her body, legal blindness, and rectal cancer requiring the creation of a colostomy (opeing in the intestines to allow feces to drain into a bag).

Record review of Resident #5's quarterly MDS, dated [DATE REDACTED] reflected a BIMS score of 10 indicating she was moderately cognitively impaired. Her Functional Status reflected she required set-up and clean up assistance with her toileting hygiene. Her Bowel and Bladder assessment indicated she had an ostomy.

Record review of Resident #5's care plan, dated 12/22/24, reflected she had a visual impairment related to being legally blind, and ADL self-care deficit related to paralysis, and had an ostomy.

Interview on 02/11/25 at 9:50 AM with Resident #5 revealed she often had to change her briefs because the staff took too long to respond to her call light. Resident #5 stated she thought staff knew if they waited, she would do it herself. She stated she did need staff assistance to make sure she was completely clean, and

she needed assistance with applying her colostomy bag to make sure it was on properly to prevent it leaking. Resident #5 stated in the evening on 02/07/25 her colostomy bag was leaking, and she was trying to clean up with her wipes. She stated CNA B answered her call light and told her he would have to get the nurse to help her. She stated LVN A came to the resident's room and told her she could not help the resident because she was the only nurse monitoring the evening meal in the dining area. She stated LVN A put a new colostomy bag on the resident's overbed table and left. Resident #5 stated she waited for about 20 minutes, and no one came to help her, so she applied the bag herself and cleaned herself up. She stated she must not have applied it correctly because later that evening the bag began to leak again. She stated a nurse from

the night shift helped her secure the bag properly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 455819 Department of Health & Human Services Printed: 09/08/2025 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 455819 B. Wing 02/15/2025

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

Arlington Heights Health and Rehabilitation Center 4825 Wellesley St Fort Worth, TX 76107

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 0691 Interview on 02/11/25 at 3:25 PM with LVN A revealed she was called to Resident #5's room by CNA B from

the dining area where she was monitoring the evening meal. LVN A stated Resident #5 told her she needed Level of Harm - Minimal harm or a new colostomy bag, so she put one on the resident's table. LVN A told her she could not help because she potential for actual harm had to get back to the dining area. LVN A stated there was a second nurse on the hall, who was supposed to care for the residents, while she was in the dining area. LVN A stated she did not notify the other nurse that Residents Affected - Few Resident #5 needed help. LVN A stated she did not follow-up with Resident #5 when she returned from the dining area.

Interview on 02/11/25 at 3:28 PM with LVN C revealed she had not been made aware of Resident #5 needing assistance with her colostomy. She stated LVN A never had a conversation with her on 02/07/25, and the interview with the surveyor was the first she time she had been made aware of the situation.

Interview on 02/12/25 at 10:35 AM with the DON revealed his expectation of the nurses would be if they could not assist a resident right away, they should have a conversation with their teammate and ask them to assist the resident. He stated that was why they had two nurses on the hall. The DON stated skin exposure to fecal matter could quickly lead to skin irritation and skin breakdown.

Record review of the facility's Ostomy Care policy, dated 2003, reflected:

.Goals

1. The resident will maintain continuous or intermittent drainage via bowel diversion without complications.

2. The resident will complete/receive correct and proper care of stoma, skin, and collection procedures.

3. The resident will be maintaining optimal skin integrity at stoma site.

.18. Persistent leakage or poorly fitted appliances can cause injury to the stoma and skin breakdown

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 455819