Health inspection·October 3, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 residents reviewed for comprehensive care plans. Residents #1's care plan failed to address the services and interventions that would be provided by the resident's hospice agency. This failure could affect the residents who received hospice services and could result in services and treatments not being coordinated. Findings included: Resident #1's admission MDS assessment dated [DATE] reflected he was a [AGE] year-old-male admitted to the facility on [DATE] with active diagnoses of congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), hypertension (a condition in which the force of the blood against the artery walls is too high), and type two diabetes mellitus (too much sugar in the blood). Resident #1 was moderately cognitively impaired, was receiving hospice care and required extensive assistance for ADLs except for eating. Review of Resident #1's electronic physician orders for October 2023 reflected no physician's order for Hospice A. Review of Hospice A's binder for Resident #1 revealed documentation of service start date of 05/05/23. Review of Resident #1's progress note dated 07/19/23 revealed: note text a [AGE] year-old male admitted on Hospice A . Resident #1's Care Plan with a date initiated on 07/24/23, created by DON revealed interventions and disciplines did not address services that would be provided by the Hospice A. Interview on 10/03/23 at 11:42 AM with the DON revealed she was aware the care plan needed to be specific about what services and interventions hospice was providing for the residents. The DON stated (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: 676080 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Town Hall Estates Arlington, Inc. 824 W Mayfield Rd Arlington, TX 76015 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)