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Complaint Investigation

Arlington Heights Health And Rehabilitation Center

September 5, 2025 · Fort Worth, TX · 4825 Wellesley St
Citations 2
CMS Rating 1/5
Beds 170
Provider ID 455819
Healthcare Facility
Arlington Heights Health And Rehabilitation Center
Fort Worth, TX  ·  View full profile →
Inspection Summary

Arlington Heights Health and Rehabilitation Center in Fort Worth, TX — inspection on September 5, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Arlington Heights Health and Rehabilitation Center

4825 Wellesley St Fort Worth, TX 76107

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Fort Worth, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Arlington Heights Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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