Inspection·June 3, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide and document sufficient preparation to ensure safe and orderly discharge from the facility for one resident (Resident #1) of five residents reviewed for discharge. Residents Affected - Few The facility failed to ensure Resident #1's home health and wound care services were confirmed and in place prior to discharge. These failures could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met. Findings included: Review of Resident #1's Face Sheet, dated 06/03/2024, revealed a [AGE] year-old male originally admitted on [DATE], re-admitted on [DATE], and discharged on 05/30/2024 with diagnoses that included: osteomyelitis of vertebra (the most common form of vertebral infection), sacral and sacrococcygeal region, Brown-Sequard syndrome (is a rare neurological condition characterized by a lesion in the spinal cord which results in weakness or paralysis on one side of the body and a loss of sensation on the opposite side), sepsis (a serious condition in which the body responds improperly to an infection), muscle weakness, lack of coordination, unsteadiness on feet, type two diabetes mellitus without complications, neuromuscular dysfunction of the bladder. Review of Resident #1's Care Plan, dated 05/31/2024, revealed Resident #1 has Sacral Stage 4 with slough and/or eschar present on admission, Resident #1 has a suprapubic catheter placed, Resident #1 has bowel incontinence immobility and paralysis Review of Resident #1's discharge MDS assessment, dated 05/30/2024, revealed resident #1's BIMS was noted as 15, which indicates the resident's cognition was intact. Resident #1 functional status documented on discharge MDS is not completed. During an interview on 06/02/2024 at 10:50 a.m. with SW revealed Resident #1's discharge was resident initiated and planned. Resident #1 was to the home on [DATE] and would transfer from home to another rehabilitation facility on 06/01/2024. SW stated once residents decide to discharge will ask resident and/or family if they require home health services and what equipment is at home, if residents require additional items for home will place referral. In this case resident refused home health, so no order or referral was provided for Resident #1 due to family member refusal of home health services. Social worker could not provide documentation of refusal. (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: 675034 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 675034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104 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)