Inspection·July 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 doorway in the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard reviewed for accidents and hazards. The facility failed to ensure residents who accessed the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard was free of hazards, when a large puddle of water was observed on July 5, 2024. The facility failed to ensure the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard was free of slip/fall hazards. Findings included: Observation on 07/05/2024 at 12:07 PM of the south hallway of Zone 3 between the vending machines and the door to the smoking courtyard revealed a large puddle of water that had entered from the gaps in the doorway and missing threshold during a brief rain shower approximately 20 minutes prior. Four residents had to be cautioned about the water on the floor while waiting for a staff member to come into the area to request the water to be cleaned up. The four residents had not noticed the water on the floor until having been alerted. Laundry Staff A had come into the hallway and was asked to get housekeeping or a staff member to clean up the water. Laundry Staff A went and got the needed supplies to clean up the water. Interview on 07/05/2024 at 12:19 PM with Laundry Staff A revealed that when it rains or when they water the plants outside, the area in the hallway between the vending machines and the door to the courtyard was known to have water and has been this way for a while. Laundry Staff A stated that housekeeping normally cleans up spills and water on the floor however they were all currently on break and unavailable. In an interview on 07/05/2024 at 1:59 PM LVN B stated that staff should not leave a liquid spill on floor. The person who finds a spill should have wiped it up or alerted housekeeping to make sure no resident had access to the area until it was cleaned. Not having a sign or person at the location would have been a safety hazard to others. Interview on 07/05/2024 at 2:06 PM with RN E revealed that it was everyone's responsibility to clean up any spills right away. RN E stated that if water or a spill was left on the floor a resident might slip and get hurt. (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 07/05/2024 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)