Pennsylvania Nursing And Rehabilitation Center

F-F689

On 4/14/2025 during a P1re- survey [sic] at [Facility Name] at [Facility Address], HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to ensure Resident #1 was free from accidents/ hazards.

The notification of the alleged immediate jeopardy states as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 675034 Department of Health & Human Services Printed: 08/29/2025 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 675034 B. Wing 04/15/2025

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

Arbor Lake Nursing & Rehabilitation LLC 901 Pennsylvania Ave Fort Worth, TX 76104

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 The facility failed to keep all residents safe from accidents/hazards when resident # 1 [sic] was allegedly shocked after plugging in her phone charger to the wall outlet on 3/16/25 in her room. Resident #1 sustained Level of Harm - Immediate a burn mark and blister from the incident. jeopardy to resident health or safety Identify residents who could be affected.

Residents Affected - Few All residents have the potential to be affected.

Identify responsible staff/ what action taken.

All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25.

All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard. Completion date of 4/14/25.

All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025.

In-Service conducted.

All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25.

All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025.

Implementation of Changes

All Staff in serviced on the event of any electrical issue or any other hazard, they will immediately place the issue in the maintenance log and follow with phone call to administrator. With completion date of 4/14/25.

All outlets in resident rooms checked by maintenance director to ensure that they are in working order and do not present a hazard. Completion date of 4/14/25.

All staff in-service [sic] on prevention of accidents, incidents and hazards. Completion date of 4/14/2025.

6 resident rooms per week x 4 weeks will be randomly audited to ensure electrical outlets are in working order.

The changes were started by the Administrator. The changes were implemented effective on 4/142025 [sic] and training was completed on 4/142025. [sic] Staff will not be allowed to work until they have been fully re-educated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 675034 Department of Health & Human Services Printed: 08/29/2025 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 675034 B. Wing 04/15/2025

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

Arbor Lake Nursing & Rehabilitation LLC 901 Pennsylvania Ave Fort Worth, TX 76104

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 All new hires will be educated on completing maintenance log to report any electrical issues or any other hazard with follow up call to administrator. Prevention of accident and incidents and hazards. [sic] Level of Harm - Immediate jeopardy to resident health or Monitoring safety

The Administrator/Designee will be responsible for monitoring the implementation and effectiveness of Residents Affected - Few in-service on 4/14/25.

The Administrator/Regional director of Operations [sic]/Maintenance director/designee will check 6 rooms weekly to ensure outlets are in working order weekly x4 weeks, then monthly thereafter and report any adverse finding during QAPI.

The Administrator/Maintenance director/designee will check maintenance log daily to check for any new risk/ electoral issues and report any adverse findings during QAPI. [sic]

Involvement of Medical Director

The Medical Director met with the Interdisciplinary team on 4/14/2025 and conducted an Ad HOC QAPI regarding ensuring all resident room outlets were checked to ensure working and not a hazard and all staff educated on accident/incident/hazard prevention, and all staff educated on reporting any electrical issues or other hazards. The Medical Director was notified about the immediate Jeopardy on 4/14/2025, the Plan of removal was reviewed and accepted by Medical Director.

Involvement of QA

An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to

review the plan of removal on 4/14/2025.

Who is responsible for the implementation of the process?

The Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 4/14/2025.

Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued

on 4/14/2025.

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

Interviews with the following staff from 04/15/25 at 9:00 AM to 3:01 PM, both in person and by phone, who worked all shifts and days of the week revealed they had been in-serviced to immediately report any electrical issues to the Administrator by phone, log the information into the Maintenance Logbook, and knew to report any accident/hazard/incident to the Administrator immediately: RN G, CNA H, CNA I, the Maintenance Director, LVN C, the ADON, RN J, CNA B, CNA D, CNA K, CNA L, the Dish Washer, LVN M,

the Dietary Aide, the COTA, CNA N, LVN O, CNA P, MA Q, MA R, LVN S, CNA T, CNA U, CNA V, CNA W, CNA X, LVN Y, CNA BB, CNA CC, LVN AA, CNA DD, MA EE, the DON, and the Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 675034 Department of Health & Human Services Printed: 08/29/2025 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 675034 B. Wing 04/15/2025

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

Arbor Lake Nursing & Rehabilitation LLC 901 Pennsylvania Ave Fort Worth, TX 76104

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 Record review of an in-service sign in sheet, dated 04/14/25, revealed 62 total staff had been in-serviced regarding Hazard/Electrical Issues. Level of Harm - Immediate jeopardy to resident health or Record review of an in-service sign-in sheet, dated 04/14/25, revealed 63 total staff had been in-serviced safety regarding Prevention of Accidents and Incidents and Hazards.

Residents Affected - Few Record review of an in-service sign-in sheet, dated 04/14/25, revealed the ADON and DON had been in-serviced regarding Accident and Incident Follow-up and care x72 hrs.

Record review of an AD Hoc Quality Assurance and Performance Improvement Plan was held on 04/14/25.

Record review of a census sheet, dated 04/14/25, reflected the Maintenance Director's initials next to each room acknowledging that he had checked each room's electrical plugs to ensure they were working and there were no hazards to the residents.

An IJ was identified on 04/14/25. The IJ template was provided to the facility on [DATE REDACTED] at 4:03 PM. While

the IJ was removed on 04/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was 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 17 of 20 675034 Department of Health & Human Services Printed: 08/29/2025 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 675034 B. Wing 04/15/2025

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

Arbor Lake Nursing & Rehabilitation LLC 901 Pennsylvania Ave Fort Worth, TX 76104

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32227 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control Residents Affected - Few program to keep the facility free of pests for 1 of 8 residents (Resident #1) reviewed for pest control.

The facility failed to prevent pests from entering the facility. On 05/28/25, Resident #1 was found in bed with ants (breed/type unknown) on his body, and he had been bitten multiple times on his torso, arms, and legs.

This failure placed residents at risk of physical harm from ant or other pest bites.

Findings included:

Record review of Resident #1's MDS dated [DATE REDACTED] reflected the resident was a [AGE] year-old male admitted to the facility 04/09/25. His diagnoses included stroke, hemiplegia (paralysis of one side of the body), anoxic brain damage (when the brain is deprived of oxygen, leading to damage brain cells) and bell's palsy (a condition that causes temporary weakness or paralysis of the muscles on one side of the face). Resident #1 had a BIMS of 0 indicating his cognition was severely impaired. The MDS further reflected the resident required substantial/maximal assistance (helper does more than half of the effort) for all ADLs.

Record review of Resident #1's care plan revised on 05/19/25 reflected the resident had an ADLs self-care performance deficit related to confusion, limited mobility, and anoxic brain damage. Interventions included

the resident would require assistance with ADLs.

Record review of Resident #1's progress notes dated 05/28/25 at 6:23 AM documented by RN A reflected

the following:

Summoned by the nurse aide that there's ants in the resident bed, arrived at the resident room noted ants on

the bed and on resident's gown, resident denies being in pain at this time. Moved the resident to his recliner, head to toe assessment noted, no ant bites noted at this time, denies being in pain, no sign of discomfort noted, bath given and transferred temporarily to [Room], Management and RP notified, closely monitoring for any changes.

Further progress notes reflected the following:

- 05/28/25 at 8:18 AM - Resident noted to have ant bites to left shoulder and upper back, [Doctor] notified with order received to hydrocortisone cream each shift.

- 05/29/25 - Redness remains on shoulder and upper back, denies any pain or itching, No signs or symptoms of infection noted .

- 05/30/25 - Resident's area of possible bites from ants are fading, redness less, denies any itching at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 675034 Department of Health & Human Services Printed: 08/29/2025 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 675034 B. Wing 04/15/2025

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

Arbor Lake Nursing & Rehabilitation LLC 901 Pennsylvania Ave Fort Worth, TX 76104

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 0925 Record review of Resident #1's physician orders for May 2025 reflected Hydrocortisone External Cream 2. 5% was orders and instructed to apply to left shoulder topically every shift for ant bites for 7 days. Level of Harm - Minimal harm or potential for actual harm Record review of the pest control log for the following dates reflected:

Residents Affected - Few - 05/28/25 - inspected and treated room [ROOM NUMBER] and 309 for ants

- 06/02/25 - replaced and treated facility for roaches and ants on the exterior

- 06/09/25 - treated for ants inside and out.

Attempts to contact RN A, CNA D, and CNA E, who worked at the time of the incident, on 06/10/25 were unsuccessful.

Observation and interview on 06/10/25 at 1:01 PM revealed Resident #1 was in bed awake. The resident denied pain and was unable to answer if he had been bitten by any ants. Resident #1's skin was observed with CNA F, and there were no signs of ant bites on the residents' shoulders and/or upper back.

Observation on 06/10/25 from 12:56 PM through 1:27 PM of Resident #1's room and six other rooms on that hall revealed there was no evidence of ants in the rooms of the hallway.

Interview on 06/10/25 at 2:12 PM, LVN B revealed she worked with Resident #1 on the 2:00 PM-10:00 PM shift the day of the incident (05/28/25). She stated she observed a few ants bites on the resident's shoulder only, and they were gone within a couple of days after that. LVN B said that during those two days, they were treating the ant bites with cream.

Interview on 06/10/25 at 2:20 PM, LVN C revealed she worked with Resident #1 on the morning shift, a few hours after the incident (05/28/25) with the ant bite. She stated she had only noted a small rash on the resident's upper shoulder. LVN C said the resident was not complaining of any discomfort and once they started to treat the ant bites with cream, the ant bites quickly faded.

Interview on 06/10/25 at 2:58 PM, the ADON revealed she was aware a resident had been bitten by ants, but

she was not aware if had been Resident #1; therefore, she did not know the details of the incident.

Interview on 06/10/25 at 3:22 PM, the DON revealed she had been told there were ants in Resident #1's room but was not told he had been bitten. The DON said the resident was moved to another room, bathed, and pest control had been called to treat the room/facility.

Record review of the facility's Pest Control policy, revised on August 2020, reflected the following:

Purpose

To ensure the Facility if free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 675034 Department of Health & Human Services Printed: 08/29/2025 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 675034 B. Wing 04/15/2025

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

Arbor Lake Nursing & Rehabilitation LLC 901 Pennsylvania Ave Fort Worth, TX 76104

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 0925 Policy

Level of Harm - Minimal harm or The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of potential for actual harm insects, rodents, and other pests

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 675034