Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect,
exploitation, or mistreatment were reported immediately to the Administrator for one (Resident #1) of eight
residents reviewed for abuse.
The facility failed to ensure LVN A immediately reported an allegation of abuse, on 03/12/24, when
Resident #1 stated he did not want to work with his overnight staff because they were rude to him, to the
Administrator (Abuse Coordinator).
This failure could place residents at risk of emotional, physical, and mental abuse.
findings included:
Record review of Resident #1's face sheet, printed on 03/27/24, revealed Resident #1 was a [AGE] year-old
male who admitted to the facility on [DATE] with acute systolic congestive heart failure, muscle weakness,
chronic obstructive pulmonary disease (restricted airflow and breathing problems), essential
hypertension(normally high blood pressure), paroxysmal atrial fibrillation(quivering or irregular heartbeat, or
arrhythmia), irritable bowel syndrome, gastroesophageal reflux(stomach acid repeatedly flows back into the
tube connecting the mouth and stomach), and constipation.
Record review of Resident #1's admission MDS assessment, dated 03/13/24, reflected Resident #1 had a
BIMS of 15, which indicated Resident #1 was cognitively intact. Section GG -Functional Abilities and Goals
indicated Resident #1 required substantial physical assistance with ADLs of toileting, bathing, dressing,
and required moderate physical assistance with ADLs of personal hygiene.
In an interview on 03/27/24 at 5:05 PM, LVN A stated he last worked with Resident #1 on the 2:00 PM to
10:00 PM shift on 03/12/24. LVN A stated while he provided toileting assistance to Resident #1 towards the
end of that shift, Resident #1 asked him if he would be his night nurse. LVN A stated he notified Resident
#1 that he would not be his night nurse and Resident #1 told him, he wish he were because he did not want
to work with his night staff because they were rude to him. LVN A stated Resident #1 did not specify what
happened or the staff involved , so he asked the oncoming nurse (LVN B), if anything had transpired the
night prior and she stated nothing had happened. LVN A stated he told LVN B to call him if he was needed
and went to his hall for the 10:00 PM to 6:00 AM shift. LVN A stated he did not report the conversation he
had with Resident #1 because he notified his assigned nurse, LVN B, and figured she would report the
statement to the administrator.
In an interview on 03/27/24 at 5:30 PM, the Administrator stated she was unaware of the statement
(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:
676317
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
676317
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Harrison at Heritage
4600 Heritage Trace Parkway
Fort Worth, TX 76244
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
Resident #1 made to LVN A on 03/12/24. The Administrator stated LVN A should have immediately notified
her of the statement made by Resident #1, as it was the responsibility of all staff to report allegations of
abuse. The Administrator stated not appropriately reporting allegations of abuse could cause uncertainty for
the resident, as they would believe their reports would go unaddressed. The Administrator stated she did
not receive any complaints from Resident #1 or his family regarding staff behavior. The Administrator stated
she h ad not received any complaints or grievances regarding any rude staff members. The Administrator
states she would begin an in-service on abuse, neglect and reporting.
An interview with Resident #1 was attempted at a local hospital on [DATE] at 2:43 p.m. but was
unsuccessful.
In an interview on 03/28/24 at 2:55 PM, LVN B stated she was Resident #1's assigned night nurse on
03/12/24. LVN B stated LVN A asked her if anything happened between her and Resident #1 the night prior,
but LVN A did not state why he asked her that. LVN B stated Resident #1 had never reported any rude staff
behavior to her nor did she recall being rude to Resident #1.
Telephone interviews were attempted with CNA C, CNA D, CNA E and CNA F (all aides on the night shift
for 03/11/24 and 03/12/24) on 03/28/24 from 3:00 PM to 3:30 PM but were unsuccessful.
In an interview on 03/28/24 at 4:46 PM, the DON stated she was unaware of the statement Resident #1
stated to LVN A on 03/12/24. The DON stated it was the facility's expectation for all allegations of abuse be
reported immediately to herself and the facility's Abuse Coordinator, who was the Administrator. The DON
stated all facility staff were responsible for reporting allegations of abuse. The DON stated she had not
received a complaint regarding staff behaviors from Resident #1 or his family. The DON stated not reporting
allegations of abuse could keep residents near the alleged abuse. The DON stated she would begin to
in-service facility staff on abuse and neglect reporting and dignity.
In a follow-up interview on 03/28/24 at 5:15 PM, the Administrator stated LVN A was suspended pending
the investigation and she had reported the incident to the State Agency.
Record review of the facility's policy entitled Abuse Prohibition Protocol, dated April 2019, read in part:
1. The patient has the right to be free from abuse, neglect, mistreatment of resident property, and
exploitation .8. Any person observing an incident of patient abuse or suspecting patient abuse must
immediately report such incidents to the Charge Nurse or Abuse Coordinator .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676317
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
676317
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Harrison at Heritage
4600 Heritage Trace Parkway
Fort Worth, TX 76244
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide residents who were unable to carry
out activities of daily living with the necessary services to maintain grooming and personal hygiene for one
(Residents #2) of eight residents reviewed for facial hair.
Residents Affected - Few
The facility failed to remove Resident #2's facial hair.
This failure could place residents at risk for social isolation, loss of dignity, and self-worth.
Findings included:
Record review of Resident #2's indicated face sheet indicated Resident #2 was a [AGE] year-old female
who admitted to the facility on [DATE] with diagnoses of influenza, Poly osteoarthritis, hypothyroidism,
transient visual loss, age related choroidal atrophy, peripheral vascular disease, and hypertension.
Record review of Resident #2's Annual MDS assessment, dated 04/12/23, revealed Resident #2 had a
BIMS of 11, which indicated Resident #2 had moderate cognitive impairment. Section GG - Functional
Abilities and Goals, Question GG0130. Self-Care revealed Resident #2 required moderate assistance with
ADLs of oral hygiene, bathing, dressing, personal hygiene and required substantial assistance with the ADL
of toileting.
Record review of Resident #2's care plan, effective 04/13/22, indicated the following:
Problems: [Resident #2's] ADL functions:
Bed Mobility Extensive x2
Transfers Extensive x2.
Dressing Extensive x2
Eating Supervision
Toileting Extensive x2
Bathing Extensive x1
Uses WC for mobility.
5/2/2023 Transfers Extensive x2
Toileting Limited x1 .
Interventions: Encourage independence, praise when attempts are made. Assist with ADL's as needed .
In an interview and observation on 03/27/24 at 2:37 PM, Resident #2 stated she was well and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676317
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
676317
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Harrison at Heritage
4600 Heritage Trace Parkway
Fort Worth, TX 76244
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
facility staff treated her well. Resident #2 was observed sitting in a recliner in her room with several white
hairs on her chin, roughly .25 inches in length. Resident #2 stated she would like to her have hairs shaven
and could not recall the last time someone asked if she would like to be shaved. She stated she had tried to
get a nurse to cut her facial hair and nails but had not been successful.
On 03/27/24 at 2:39 PM, the surveyor notified LVN G that Resident #2 had facial hair that she would like
shaved. LVN G stated she was uncertain of where Resident #2's aide or nurse was, but she would ensure
Resident #2's chin was shaved. LVN G was observed to ask Resident #2 if she wanted her chin hairs
shaved. Resident #2 agreed and LVN G shaved her chin.
In an interview on 03/27/24 at 4:32 PM, RA H stated she was the restorative aide for the facility. RA H
stated her responsibilities included providing showers to residents, assisting with grooming and whatever
was needed on the floor during her shift. RA H stated Resident #2's family member would normally visit her
and pluck her chin hairs, but she believed she had not visited recently to pluck them. RA H stated she was
unaware that Resident #2 was observed with long chin hairs and stated she would ask Resident #2 if she
would like her chin shaved.
In an interview on 03/27/24 at 5:05 PM, LVN A stated he was the 2:00 PM to 10:00 PM nurse for Resident
#2. LVN A stated it was expected for nursing staff to groom residents daily; including shaving residents. LVN
A stated he did not recognize the facial hair on Resident #2's chin. LVN A stated it was the responsibility of
the aides and nurses to ensure residents were groomed to their liking. LVN A stated not being groomed
could affect residents' self-image.
In an interview on 03/27/24 at 5:30 PM, the Administrator stated she was unaware of the facial hair
observed on Resident #2's chin. The Administrator stated it was the facility's expectation for residents to be
groomed during showers and daily as needed. The Administrator stated women having facial hair could be
a dignity issue. The Administrator stated she would begin to in-service staff on ADLs, grooming and dignity,
and she would have facility management staff to do ADL checks to ensure all grooming was provided as
needed.
Record review of the facility's policy entitled Activities of Daily Living, dated May 2016, read in part:
1. Every effort must be made to assure that assignments of nurses and nurse aides to patients are as
consistent possible .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676317
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
FAQ · About this visit
Common questions about this visit
What happened during the March 29, 2024 survey of The Harrison at Heritage?
This was a inspection survey of The Harrison at Heritage on March 29, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at The Harrison at Heritage on March 29, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.