Health inspection·May 29, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure when discharge is anticipated, a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #1's face sheet, dated 05/29/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Record review of Resident #1's Discharge MDS Assessment, dated 02/11/25, reflected Resident #1 was discharged to Long-Term Care Hospital without a return anticipated. Resident #1 had diagnoses which included unspecified dementia (decline in mental ability, affecting thinking, and memory), anxiety disorder (a type of mental health condition), bipolar disorder (extreme mood swings, ranging from periods of elevated mood), schizophrenia (a chronic brain disorder that affects thinking, feeling, and behavior), and insomnia (sleep disorder), unspecified . Resident #1 cognitive skills for daily decision making was modified independence. Resident #1 required maximal/moderate assistance with toileting, showering and personal hygiene. Record review of Resident #1's physician order, dated 02/11/25, reflected May transfer out to [Hospital]. Record review of Resident #1's nursing progress note by LVN A, dated 02/11/25 at 14:30 [2:30 PM], reflected Res. has discharged to [Hospice Name] in [city]. Res. alert and oriented x3, able to make needs known. Res. stable, no c/o pain or discomfort. Wheeled to front door for his transportation to [city]. 127/65, 71, 18, 97.9, 96% RA. Record review of Resident #1's Summary Episode Note, dated/timed 02/11/24 8:40 PM, reflected (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: 455872 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 05/29/2025 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)