Health inspection·November 3, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for one (Resident #1) of one resident reviewed for PASRR services. The facility failed to order a standing board for Resident #1 based on PASRR assessment for specialized services. This failure could place residents at risk of not receiving specialized PASRR services which could contribute to a decline in quality of life, physical, mental, and psychosocial well-being . Findings include: Record review of Resident #1's face sheet, dated 11/03/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizoaffective disorder, depressive type, unspecified intellectual disabilities, and cognitive communication deficit. Record review of Resident #1's care plan, revised 8/22/23, reflected he was evaluated for PASRR for services for a standing board service for DD (Muscle wasting and atrophy). Interventions included: Obtain a soft padded standing board specialized equipment recommended by Physical therapy, to help resident stand longer with minimal pain against his lower legs against the standing board. Record review of Resident #1's annual MDS assessment, dated 9/10/23, reflected Resident #1 was wheelchair dependent. He could communicate some words or could finish thoughts if prompted or given time in making daily decisions. Resident #1 required partial/moderate assistance - helper did less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort assistance with ADL care. He was considered by the state PASRR evaluation. Record review of Resident #1's service plan with IDT with the Rehabilitation Director, Social Worker, MDS Coordinator, LAR, and Speech/Language/Cognitive therapies was held on 6/01/23 reflected an outcome of meeting was skilled service: To prevent decline in function, improve attention/concentration, and enhance cognitive skills to enhance residents' quality of life by improving ability to participate in functional activities of choice and a new electric wheelchair with a reclining high back. Record review of Resident #1's IDT meeting with LAR on 8/13/23 reflected a soft standing board was recommended by Director of Rehabilitation (DOR) for Resident #1 to achieve a better outcome in his standing during therapies by using a soft padded standing board. 73 days after the IDT meeting and (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 4 Event ID: 675930 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 675930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbrook Plaza 401 W Arbrook Blvd Arlington, TX 76014 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)