Arlington Heights Health And Rehabilitation Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and down the hallway. The Administrator said that Resident #2 liked to go into the last room on the right side of the hallway. The Administrator said Resident #2 walked into the room and Resident #3 walked in behind her. The Administrator said when Resident #3 walked in, Resident #2 closed the door on her and then Resident #3 pushed on the door harder. The Administrator said when the door opened, Resident #3 grabbed Resident #2 and they both started hitting each other. The Administrator said Resident #2 had a scratch under her eye that was superficial and did not require any further treatment. The Administrator said Resident #3 was placed on 1:1 monitoring since she initiated the first contact with Resident #2. The Administrator said staff were in-serviced on abuse, resident-to-resident altercations, and behaviors. The Administrator said the door to the room they tried going into was also now locked so that they could not go

in there anymore. The Administrator said all residents had the right to be free from abuse, even from each other. The Administrator said all staff were responsible for ensuring that any resident in the facility was free from abuse. The Administrator said the incident that occurred between Residents #2 and #3 was considered physical abuse. The Administrator said if residents were not free from abuse they could suffer physical or mental anguish from the situation. The Administrator said he expected all staff to ensure residents were free from abuse. Record review of an in-service dated 07/17/25 and titled Approaching and calming residents with Dementia, revealed 90 staff had been in-serviced. Record review of an in-service dated 07/17/25 and titled Resident to Resident Abuse, revealed 90 staff had been in-serviced. Record

review of the facility's Abuse/Neglect policy, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart.Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. 2. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. 6. Should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented in the nurses' notes.

Director of Nursing Services should be notified of elopement. 7. If a resident is discovered to be missing, a search shall begin immediately. Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

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