Inspection·June 4, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately but not later than 2 hours after the allegation was made to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for abuse. LVN A failed to immediately report an abuse allegation to the Administrator, who was the facility's abuse coordinator, when she overheard CNA B verbally abusing Resident #1 in early May 2025. This failure could have caused residents to experience abuse by staff. Findings included: Record review of Resident #1's admission Record, dated 06/04/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 04/01/25, reflected she had a BIMS score of 06, which indicated severe cognitive impairment. Her active diagnoses included Non-Alzheimer's Dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities), Schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), and Borderline Personality Disorder (a mental health condition that affects the way people feel about themselves and others). Observation and attempted interview on 06/04/25 at 10:00 AM with Resident #1 revealed she was lying in bed in her room. Resident #1 did not answer any questions the surveyor asked, instead she just stared at the surveyor. Interview on 06/04/25 at 9:31 AM with LVN A revealed she worked with Resident #1 on the secured unit. LVN A said she saw CNA B go in to provide care to Resident #1 one day in early May 2025 and overheard the aide tell the resident, You need to get your pissy ass back in bed. LVN A said she wrote out a witness statement and turned it into the Administrator who was the Abuse Coordinator for the facility since this was an instance of verbal abuse. Interview on 06/04/25 at 10:15 AM with the Administrator revealed he had not received any witness statements regarding an abuse allegation and CNA B or Resident #1. Interview on 06/04/25 at 10:52 AM with CNA B revealed she cared for Resident #1 but had never abused her. CNA B said she never said anything verbally abusive towards Resident #1 or any other (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 06/04/2025 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)