Inspection·November 8, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was a written notification that Resident #1 would be discharged from [nursing facility] 30 days from the date of the letter due to refusal to adhere to the smoking policy set by the facility Administrator. The notice included information on how to contact the Ombudsman and was signed by the former Administrator, ADON, and a notation that Resident #1 refused to collect and sign. Record review of a letter titled Immediate and Effective Discharge Collection Letter, dated 10/02/24, reflected it was a written notification that Resident #1 would be immediately and effectively discharged from [nursing facility] due to refusal to adhere to the smoking policy set by the facility Administrator. The notice reflected the Social Worker would work with Resident #1 to make necessary preparations for a safe transition. The notice also included information on how to contact the Ombudsman. Further review reflected no handwritten signatures or notations regarding lack of signatures. Record review of Resident #1's progress notes, 10/02/24-11/08/24, reflected there was no documentation to show that Resident #1 and the Ombudsman were provided with or attempted to be provided with a written copy of the immediate and effective discharge collection letter. Record review of Resident #1's care plan conference note, dated 10/02/24, reflecte it could not initially be viewed by the investigator in the electronic record due to it not being completed and signed. The note reflected that it could only be edited, printed, or completed. The ADON later provided a hard copy of the care plan conference note that was locked and signed by the DON on 11/08/24 at 12:17 PM and reflected in part the following: [Resident #1] requested to meet [Ombudsman], after she was found violating smoking policy, [Ombudsman] present in the meeting and [Resident #1] admitted that she violated the smoking policy and that she will not follow the facilities [sic] rule of supervised smoking and will not return paraphernalia. Facility issues her notice immediate/effective discharge. In an interview on 11/07/24 at 09:25 AM, the DON stated Resident #1 had been discharged from the facility because she was non-compliant with the facility's smoking policy. The DON stated Resident #1 refused to turn in her lighter and cigarettes and would go outside and smoke whenever she wanted, outside of scheduled smoke times. The DON stated the behavior was dangerous to Resident #1 and other residents in the facility. The DON stated Resident #1 was issued an immediate discharge on [DATE] during a care plan meeting with the Ombudsman and the former Administrator. The DON stated Resident #1 also had labs drawn on 10/02/24 that came back critical for low sodium and the resident was sent to the local hospital. In an interview on 11/07/24 at 03:56 PM, a representative at the local hospital stated Resident #1 arrived at the hospital on [DATE] and was diagnosed with low sodium which was a reason for her to be admitted . The representative stated Resident #1 was medically cleared and ready for discharge on [DATE]; however, the facility refused to allow the resident to return to the facility and Resident #1 had been at the hospital for 34 days with no place to go. The representative stated the facility informed them that Resident #1 had been issued a 30-day notice of discharge from their facility due to non-compliance with the smoking policy. The representative stated he understood the facility's reason for discharging Resident #1; however, if she was issued a 30-day discharge notice and was still within the 30 days, the facility should have been responsible for taking Resident #1 back to the facility and helping her find alternative placement. In an interview on 11/07/24 at 04:53 PM, the Ombudsman stated she recalled having to visit with Resident #1 on multiple occasions to convince her to turn over smoking paraphernalia and follow the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455872 If continuation sheet Page 2 of 4 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 455872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Residence and Rehabilitation Center 405 Duncan Perry Rd Arlington, TX 76011 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smoking policy; however, the resident always refused. The Ombudsman stated she last visited Resident #1 a day or two before she discharged to the hospital to again attempt to collect smoking paraphernalia and the resident refused. The Ombudsman stated she informed the former Administrator to follow the facility's policy and do what they needed to do as far as discharging Resident #1. The Ombudsman stated she was aware of the 30-day discharge notice that had been issued to Resident #1 at the end of September 2024; however, she was not aware of an immediate discharge notice issued on 10/02/24. The Ombudsman stated she was aware that the facility wanted to discharge Resident #1 because her behavior was a safety hazard; however, they had issued and rescinded discharge notices on multiple occasions to give the resident a chance to cooperate. The Ombudsman stated she could not recall receiving an official immediate discharge letter for Resident #1, but she needed to check her emails to confirm. In an interview on 11/08/24 at 09:42 AM, Resident #1 stated she was currently at [local hospital] waiting for the Social Worker to find her a place to stay because [nursing facility] would not allow her to go back until they got a new administrator. Resident #1 stated she admitted to the hospital on [DATE] and was ready for discharge just a few days later. Resident #1 stated [nursing facility] refused to take her back because she did not follow their smoking policy. Resident #1 stated she was given a 30-day discharge notice a couple of weeks before being sent out to the hospital, so she still had time at the facility to work with them and the Ombudsman to find placement. Resident #1 stated she was not issued an immediate discharge notice prior to going to the hospital and was only aware of the 30-day notice. In further interview on 11/08/24 at 9:48 AM, the Ombudsman stated according to her notes, she visited Resident #1 on 10/01/24 after the facility continuously called her about the resident's non-compliance with the smoking policy. The Ombudsman stated her note reflected that Resident #1 could be discharged ; however, there was not an official immediate discharge notice sent to her. In an interview on 11/08/24 at 12:28 PM, the Corporate Nurse stated the facility was currently without an administrator and they had 30 days to find a replacement. She stated she was maintaining her position as the corporate nurse; therefore, all documentation left by the former Administration regarding the discharge of Resident #1 should be reviewed. The Corporate Nurse did not provide any further details. In further interview on 11/08/24 at 01:26 PM, the DON stated she was not normally responsible for discharges and placement of residents. The DON stated she would only provide clinical information as needed. The DON stated the social worker and administrator handled the discharge process; however, the facility did not currently have a social worker or an administrator. The DON stated the former Administrator who dealt directly with the discharge of Resident #1 was no longer with the company and all they had were her notes. The DON stated Resident #1 was aware that she was receiving an immediate discharge because it was mentioned in the care plan meeting held on 10/02/24 and there was also an immediate discharge letter in the former Administrator's file. The DON stated the immediate discharge letter was not signed by Resident #1 because she always refused to sign anything that was given to her. The DON stated since she did not deal directly with the discharge, she could not confirm that an official immediate discharge letter had been provided to the Ombudsman. The DON stated the risk of not properly notifying a resident/RP and ombudsman of a discharge could be the resident not being assisted with finding placement and being safely discharged . Record review of the facility's Transfer or Discharge, Emergency policy and procedure, revised December 2016, reflected in part the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455872 If continuation sheet Page 3 of 4 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 455872 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arlington Residence and Rehabilitation Center 405 Duncan Perry Rd Arlington, TX 76011 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 0623 Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation Residents Affected - Few 1. Residents will not be transferred unless: a. The safety of individuals in the facility is endangered due to clinical or behavioral status of the resident. .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution our facility will implement the following procedures: .c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; .g. Others as appropriate or as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455872 If continuation sheet Page 4 of 4