Inspection·June 7, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of four residents observed for infection control. Residents Affected - Few The facility failed to prevent Resident #1's indwelling urinary Foley catheter device from contact with the floor. This failure could place the residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #1's Face Sheet, dated 06/07/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. One of his diagnoses was obstructive and reflux uropathy (a condition where urine cannot flow because of blockage in the urinary tract). Review of Resident #1's Quarterly MDS Assessment, dated 05/04/2024, reflected Resident #1 had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment also indicated the resident had an indwelling catheter. Review of Resident #1's Comprehensive Care Plan, dated 05/11/2024, reflected Resident #1 had an indwelling catheter due to obstructive uropathy and one of the interventions was to the anchor catheter to prevent tension. Review of Resident #1's Physician Order, dated 10/04/2023, indicated, Monitor F/C q shift for leakage, blockage, sediment buildup, or low output. Every shift. Observation and interview with Resident #1 on 05/25/2023 at 10:12 AM revealed Resident #1 was in his bed, resting. Resident #1 had a Foley catheter tubing hanging at the side of the bed. At the end of the Foley catheter tubing, a catheter bag was attached. The catheter bag was observed flat on the floor. Resident #1 stated he had a catheter even before he was admitted to the facility. He said he was not aware if the staff would hang the catheter or not. Observation and interview with LVN A on 05/25/2024 at 2:42 PM, LVN A stated the catheter bag should have been off the floor because it could cause infection. LVN A went inside the resident's room and acknowledged that Resident #1's catheter bag was on the floor. LVN A put on a pair of gloves, picked up the catheter bag, hung it on the railing below the bed, and put the catheter bag in a privacy (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: 455819 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 455819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2024 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)