Inspection·July 10, 2024

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 (Resident #1) of 3 residents reviewed for involuntary seclusion. Residents Affected - Few The facility failed to ensure the ADON did not tip Resident #1's wheelchair forward, dump him onto his bed, remove his wheelchair from the room, and close the resident's door. This failure could place residents at risk of injury, falls from bed, and decreased sense of self worth. Findings included: Record review of Resident #1's undated admission Record reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which including stroke, history of falls, and depression. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 2, which indicated he had severe cognitive impairments. His Functional Status reflected he required complete assistance with his ADLs except eating. Resident #1's Mobility Assessment reflected he required partial assistance with transfers. Record review of Resident #1's care plan, dated 05/28/24, reflected he had impaired cognitive processes, and impaired communication related to his stroke. Record review of Resident #2's undated admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included paralysis below the waist, and depression. Record review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score of 15 which indicated he was cognitively intact. Record review of the facility's investigation report reflected the ADON was witnessed to have taken Resident #1 into his room, via his wheelchair, and tilting the wheelchair forward so that Resident #1 fell onto his bed. The ADON then left the room with Resident#1's wheelchair and closed the door. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455576 Printed: 05/15/2026 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 455576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richland Hills Rehabilitation and Healthcare Cente 3109 Kings CT Fort Worth, TX 76118 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)