Inspection·April 17, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few called 911, to report the incident, while other nurses started a first aide treatment, to stop bleeding on the laceration. 911 was called for immediate intervention, because [Resident #2] was uncontrollably displaying aggressive behavior, trying to hit or attack any staff that come close to her. Resident [#1] was taken to [the hospital] ER for further treatment. DON and resident's responsible party was notified of the incident [sic]. - On 03/28/24 at 4:01 AM LVN B wrote: Re admitted on a stretcher with head injury . no active bleeding no swelling noted to the head .[sic]. Review of Resident #1's hospital records, dated 03/27/24, reflected she was seen at the hospital for a scalp laceration and alleged assault. Resident #1 had a head injury and scalp laceration with staples. Observation and interview on 04/17/24 at 11:00 AM with Resident #1 revealed she was laying in her bed and due to her condition could only answer yes or no questions. Resident #1 was asked if she had been hit before by anyone at the facility and she said yes. Resident #1 was asked if it was a resident that hit her and she said yes. Resident #1 was asked if she knew why the resident hit her and she said no. Resident #1 was asked if she was in any pain from the incident and she gave a hand gesture to indicate sometimes. Resident #1 was asked if she went to the hospital and she said yes. Resident #1 was asked if she received staples to her head because of what happened and she said yes. Resident #1 was asked if she was scared of anyone in the facility and she said no. Resident #1 was asked if she was fearful to leave her room and she said no. Resident #1 was asked if she felt safe in the facility and she said yes. Resident #1 was asked if she still had the staples in her laceration and she said no. Resident #1 was observed to not have any injury to her head at the time of the interview. Resident #2 Review of Resident #2's face sheet, dated 04/17/24, reflected the resident was a [AGE] year-old female who originally admitted on [DATE] and discharged on 03/27/24. Her diagnoses included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), unspecified psychosis ( This mental state is characterized by a loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes), and Alzheimer's disease (a brain disorder that gets worse over time. It is characterized by changes in the brain that lead to deposits of certain proteins). Review of Resident #2's annual MDS Assessment, dated 01/17/24, reflected she had a BIMS score of 07 indicating moderate cognitive impairment. Further review reflected she did not have any physical or verbal behavioral symptoms directed towards others. Review of Resident #2's undated care plan reflected the following: Focus: Resident has episodes of unwanted behaviors as evidence by: aggression/agitation toward others .Goal: Behavior episodes will be reduced to less than daily over the next 90 days .Interventions: Monitor for early warning signs of behavior-approach in calm manner, call by name, remove from unwanted stimuli. Review of Resident #2's progress notes reflected the following: - On 03/27/24 at 8:19 PM LVN C wrote: This writer was at the nursing station at about 1800 [6:00PM] working on the computer. This resident [Resident #2] was at the nursing station at the other side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of the nursing station behind this writer. Resident was talking to herself as she usually does. I was concentrating on what I was doing on the computer, then I heard a sound twice, and I turn around to find out where the sound is coming from, I saw this resident holding a wooden back scratcher above her face and standing close to [Resident #1] who was quietly watching TV in the nursing station and [Resident #2] was talking aggressively in [Resident #2's native language] to this patient who is nonverbal. As I ran and held her she was still making an attempt to hit [Resident #1]. I tried to remove [Resident #2] away from [Resident #1], she held the wooden back scratcher very strong and throw herself on the floor and continue to display uncontrollably aggressive behavior to staffs. The nurse assigned to both resident came and saw [Resident #1] bleeding from her ear and head, she call emergency response [sic]. Review of an incident report, dated 03/27/24, completed by LVN A revealed Resident #1 suffered a laceration to the top of her scalp. Review of the facility's provider investigation report reflected the date the incident occurred was 03/27/24 at 6:00 PM and the date the incident was reported was 03/28/24 at 9:26 AM. The description of the allegation revealed [Resident #2] (perpetrator) hit another resident, [Resident #1] with a back scratcher on the back of her head causing a laceration. The investigation findings were confirmed, indicating Resident #2 had abused Resident #1. Attempted interview via phone on 04/17/24 at 10:17 AM with LVN A was unsuccessful. Attempted interview via phone on 04/17/24 at 10:06 AM with LVN C was unsuccessful Interview on 04/17/24 at 11:31 AM with the DON revealed she was contacted by staff the evening of 03/27/24 to report the altercation between Residents #1 and #2. The DON said Resident #1 was sitting at the nurse's station watching TV and was aphasic meaning she could not respond to anyone verbally. The DON said Resident #2 spoke a different language and gets frustrated when those around her do not speak back to her because they do not understand her. The DON said Resident #2 had tried talking to Resident #1, who did not respond to her, and Resident #2 hit Resident #1 on the head with a wooden back scratcher. The DON said Resident #1 sustained a laceration on the side of her head near her left ear. The DON said the residents were separated immediately and 911 was called. The DON said staff noticed Resident #1 was bleeding and applied pressure to the wound and an ice pack until EMS arrived. The DON said Resident #1 was sent to the hospital for the laceration which needed 3 staples and was about an inch long. The DON said Resident #1 returned to the facility a few hours later. The DON said she contacted the Interim Administrator who was the facility's abuse coordinator. The DON said she volunteered to report all abuse allegations to HHSC instead of the Interim Administrator. The DON said she also in-serviced all staff regarding abuse/neglect and resident to resident altercations. The DON said she and the Interim Administrator discussed when the incident should be reported and agreed it would be reported the next day (03/28/24) to be within 24 hours. The DON said she did not believe the laceration to be a serious bodily injury because it was superficial and she would only consider it to be a serious bodily injury if Resident #1 also had internal bleeding. The DON said she also did not consider this to be an abuse allegation because Resident #2 had dementia and her actions and behaviors were not intentional towards Resident #1. The DON said she did not realize she had confirmed the abuse allegation on the provider investigation report and said this situation regarding Residents #1 and #2 did not involve abuse. The DON said the purpose of abuse allegations being reported timely was because anything could happen after the incident. The DON said the risk of not reporting abuse allegations timely was that the incident could happen again. The DON said the Interim Administrator was not at the facility and in a meeting at a different location today (04/17/24). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676080 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 676080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's policy, revised July 2017, and titled Abuse Investigation and Reporting reflected: .Reporting: 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury Event ID: Facility ID: 676080 If continuation sheet Page 4 of 4