Health inspection·November 26, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Residents #1) reviewed for abuse and neglect. The facility failed to report an incident where Resident #1 was found with a call light around his neck on 08/26/25. This failure could place residents at risk of neglect, injury, and lack of timely reporting of incidents. Findings included:Record review of the facility's current Abuse Prohibition Protocol policy, dated 08/25, revealed the following: .5. The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment. 7. i. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.10. The Abuse Prevention Coordinator will:a. Immediately (within 2 hours) report to the State agency and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The State agency and other appropriate authorities as required under applicable regulations and regulatory guidance. Record review of Resident #1's MDS Five Day assessment, dated 07/28/25, reflected the resident was an [AGE] year-old male, admitted to the facility on [DATE]. The resident's diagnoses included anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), cerebral infarction unspecified, (occurs when there is a disrupted blood flow to the brain), and hemiplegia following cerebral infarction affecting left nondominant side). This MDS reflected Resident #1 had moderate cognitive impairment with a BIMS score of 10. The MDS Section D0150 Resident Mood Interview further reflected Resident # 1 did not exhibit symptoms of feeling down, depressed, or hopeless and had no symptoms of having little interest or pleasure in doing things. Record review of Resident #1's hospital records, dated 07/17/25, reflected no suicidal ideations while Resident #1 was in the hospital previous to admission to the facility. Record review of Resident #1's care plan, dated 07/22/25, reflected the resident used psychotropic medication related to depression. Interventions included the resident would remain free of psychotropic related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Further review of Resident #1's care plan initiated on 10/09/25 did not reflect any history of having suicidal ideations/behaviors. Record review of Resident #1's clinical record did not reflect any suicidal ideations. Record review of Resident #1's progress notes dated 08/26/25 at 9:00 AM by LVN A reflected: Resident observed in bed. Patient Page 1 of 6 676317 676317 11/26/2025 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alert and oriented x 2. Patient exhibited signs of agitation. Attempted to provide care to the resident. Resident refused care and proceeded to pull off the call light off the wall and wrap the cord around his neck. Patient then shouted out loud pull the cord I am better off dead than alive. Give me a bottle of sleeping pills. Resident become outrate [sic], unable to redirect. Notified MD, NP, and DON. New order received to send patient to . Hospital for psych evaluation. Family notified. Record review of Resident #1's progress notes, dated 08/26/25 at 9:02 AM, by DON reflected: Responded to the patient's room after being called by the nurse. The nurse reported that the patient had been attempting to wrap a cord around his neck. At the time of arrival, the nurse was holding the call light cord and was explaining to the patient that he could not use it in that manner. Upon speaking with the patient he expressed that he was upset about being placed in a nursing home. He shared that his daughter had told him he should just kill himself. He continued to ask for the cord, at which point I removed any objects from the room that could pose a risk of self-harm. The nurse manager and I remained in the room and performed a head to toe assessment to ensure that the patient had not caused himself any physical harm. I then assigned a staff member to stay in the room with the patient at all times, instructing them not to leave under any circumstances, as one-on-one monitoring was now required. Resident stated that he knows we love him just is sad because of his family. Resident assisted up to chair, resident barely has clothes, so staff went to laundry to get sweatpants for patient to wear. Resident in good spirits awaiting transportation. Record review of Resident #1's Head to Toe assessment, dated 08/26/25, completed by DON reflected: No markings around neck. No new skin concerns. Skin with no new areas.Record review of Resident #1's Change in Condition, dated 08/26/25 at 10:11 AM, by LVN A reflected: .Altered Mental Status on 08/26/25. This condition, symptom or sign has occurred before: No. Resident alert and oriented, knows what he is talking about. Appears distressed and agitated. Stated that he is better off dead than alive. Resident need psych eval. Mental status changes-Suicidal thoughts. Record review of a Situation Background Appearance Review and Notify Report for Resident #1, dated 08/26/25 by LVN A, reflected: The condition, symptom, or sign has occurred before: No. Altered level of consciousness. Danger to self or others. Sent to .Hospital. Interview on 10/09/25 at 11:54 AM, LVN A revealed he was Resident #1's 6:00 AM - 2:00 PM nurse. LVN A revealed that he went into Resident #1's room and found him with his call light cord out of the wall and had wrapped it around his neck. LVN A stated he took the cord from around Resident #1's neck and notified the DON, who came to Resident #1's room immediately. LVN A revealed the cord was not tight around the resident's neck and said there was no redness or injuries noted to his neck. LVN A stated that he notified the doctor and received an order to send Resident #1 out to the hospital for a psychiatric evaluation. LVN A said Resident #1 was kept on one-on-one supervision until the resident was picked up by the ambulance that same day. LVN A revealed the DON and Clinical Unit Manager cleared Resident #1's room of all sharp items and cords to prevent Resident #1 from harming himself while they were waiting for an emergency transport for Resident #1. LVN A also stated Resident #1 had not expressed any intent or suicidal ideations prior to this event. LVN A stated Resident #1 went to the dining room for all his meals and had not isolated himself prior to this incident. Interview on 10/09/25 at 12:06 PM, CNA B revealed she was Resident #1's 6:00 AM - 2:00 PM CNA. CNA B stated the resident had never expressed suicidal ideations prior to the incident. CNA B said that after the incident, Resident #1 said his daughter had dropped him off and left him at the facility therefore he felt like he wanted to die. CNA B revealed that Resident #1 was kept on one-on-one supervision until he was picked up by emergency transport and transported to the hospital. Interview on 10/09/25 at 4:22 PM, the Clinical Unit Manager revealed she and the DON responded to LVN A when he notified them about 676317 Page 2 of 6 676317 11/26/2025 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 and the call light around his neck. The Clinical Unit Manager stated that Resident #1 was distraught at the time and stated that no one wanted him and that he was not going to get better. The Clinical Unit Manager said that she and the DON removed all items out of Resident #1's room that could be used to harm himself. The Clinical Unit Manager also stated she and the DON placed Resident #1 on one-on-one supervision until emergency transport arrived to take him to the hospital for a psychiatric evaluation. The Clinical Unit Manager said Resident #1 did not have suicidal ideations or mentioned that he felt like hurting himself prior to the incident. The Clinical Unit Manager revealed the Administrator was responsible for reporting incidents to the State. The Clinical Unit Manager also said that if the Administrator was not available to report to the State, the DON could report to the State when needed. Interview on 10/09/25 at 4:38 PM, the DON revealed that she was notified by LVN A that Resident #1 was stating that he was going to kill himself. The DON stated that she responded and went to Resident #1's room immediately. The DON said that Resident #1 was told by his daughter that he was useless during a visit. The DON said that she talked to Resident #1 calmly and took the things out of his room that could be a harm to him such as cords. The DON said the facility received an order to send Resident #1 out for a psychiatric evaluation. The DON stated the Administrator was responsible for reporting unusual events and she (DON) would be responsible if the Administrator was out of the building. The DON stated Resident #1 was picked up by emergency transportation later that day. However, Resident # 1 was placed on one-one-one until emergency transport arrived and the resident did not return from the hospital. Interview on 10/09/25 at 5:28 PM, the Administrator revealed that she was immediately notified of Resident #1's incident. The Administrator stated, Resident #1 did not appear depressed prior to this incident, and he had not expressed suicidal ideations. The Administrator stated that Resident #1 was placed on one-on-one supervision after the incident and then sent out for a psychiatric evaluation and did not return from the hospital. The Administrator also revealed that a head-to-toe assessment had been completed, and no redness or red marks were found on the resident's neck. The Administrator also stated that after the resident was found, they developed a new assessment which would have the resident placed on one-on-one supervision, would be referred to psychiatric serviced, and sent out for psychiatric evaluation. The Administrator stated they in-serviced immediately on this new policy after Resident #1 was found in his room. The Administrator stated she reviewed the regulations with her upper management, and felt this incident was not reportable. 676317 Page 3 of 6 676317 11/26/2025 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 ensure all alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect.The facility failed to implement their policy on reporting an incident involving Resident #1 when he was found with a call light cord around his neck on 08/26/25. This failure could place residents at risk of and contribute to neglect. Findings included: Record review of Resident #1's MDS Five Day assessment, dated 07/28/25, reflected the resident was an [AGE] year-old male, admitted to the facility on [DATE]. The resident's diagnoses included anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), cerebral infarction unspecified, (occurs when there is a disrupted blood flow to the brain), and hemiplegia following cerebral infarction affecting left nondominant side). This MDS reflected Resident #1 had moderate cognitive impairment with a BIMS score of 10. The MDS Section D0150 Resident Mood Interview further reflected Resident # 1 did not exhibit symptoms of feeling down, depressed, or hopeless and had no symptoms of having little interest or pleasure in doing things. Record review of Resident #1's hospital records, dated 07/17/25, reflected no suicidal ideations while Resident #1 was in the hospital previous to admission to the facility. Record review of Resident #1's care plan, dated 07/22/25, reflected the resident used psychotropic medication related to depression. Interventions included the resident would remain free of psychotropic related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Further review of Resident #1's care plan initiated on 10/09/25 did not reflect any history of having suicidal ideations/behaviors. Record review of Resident #1's clinical record did not reflect any suicidal ideations. Record review of Resident #1's progress notes dated 08/26/25 at 9:00 AM by LVN A reflected: Resident observed in bed. Patient alert and oriented x 2. Patient exhibited signs of agitation. Attempted to provide care to the resident. Resident refused care and proceeded to pull off the call light off the wall and wrap the cord around his neck. Patient then shouted out loud pull the cord I am better off dead than alive. Give me a bottle of sleeping pills. Resident become outrate [sic], unable to redirect. Notified MD, NP, and DON. New order received to send patient to . Hospital for psych evaluation. Family notified. Record review of Resident #1's progress notes, dated 08/26/25 at 9:02 AM, by DON reflected: Responded to the patient's room after being called by the nurse. The nurse reported that the patient had been attempting to wrap a cord around his neck. At the time of arrival, the nurse was holding the call light cord and was explaining to the patient that he could not use it in that manner. Upon speaking with the patient he expressed that he was upset about being placed in a nursing home. He shared that his daughter had told him he should just kill himself. He continued to ask for the cord, at which point I removed any objects from the room that could pose a risk of self-harm. The nurse manager and I remained in the room and performed a head to toe assessment to ensure that the patient had not caused himself any physical harm. I then assigned a staff member to stay in the room with the patient at all times, instructing them not to leave under any circumstances, as one-on-one monitoring was now required. Resident stated that he knows we love him just is sad because of his family. Resident assisted up to Residents Affected - Few 676317 Page 4 of 6 676317 11/26/2025 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few chair, resident barely has clothes, so staff went to laundry to get sweatpants for patient to wear. Resident in good spirits awaiting transportation. Record review of Resident #1's Head to Toe assessment, dated 08/26/25, completed by DON reflected: No markings around neck. No new skin concerns. Skin with no new areas. Record review of Resident #1's Change in Condition, dated 08/26/25 at 10:11 AM, by LVN A reflected: .Altered Mental Status on 08/26/25. This condition, symptom or sign has occurred before: No. Resident alert and oriented, knows what he is talking about. Appears distressed and agitated. Stated that he is better off dead than alive. Resident need psych eval. Mental status changes-Suicidal thoughts. Record review of a Situation Background Appearance Review and Notify Report for Resident #1, dated 08/26/25 by LVN A, reflected: The condition, symptom, or sign has occurred before: No. Altered level of consciousness. Danger to self or others. Sent to .Hospital. Interview on 10/09/25 at 11:54 AM, LVN A revealed he was Resident #1's 6:00 AM - 2:00 PM nurse. LVN A revealed that he went into Resident #1's room and found him with his call light cord out of the wall and had wrapped it around his neck. LVN A stated he took the cord from around Resident #1's neck and notified the DON, who came to Resident #1's room immediately. LVN A revealed the cord was not tight around the resident's neck and said there was no redness or injuries noted to his neck. LVN A stated that he notified the doctor and received an order to send Resident #1 out to the hospital for a psychiatric evaluation. LVN A said Resident #1 was kept on one-on-one supervision until the resident was picked up by the ambulance that same day. LVN A revealed the DON and Clinical Unit Manager cleared Resident #1's room of all sharp items and cords to prevent Resident #1 from harming himself while they were waiting for an emergency transport for Resident #1. LVN A also stated Resident #1 had not expressed any intent or suicidal ideations prior to this event. LVN A stated Resident #1 went to the dining room for all his meals and had not isolated himself prior to this incident. Interview on 10/09/25 at 12:06 PM, CNA B revealed she was Resident #1's 6:00 AM - 2:00 PM CNA. CNA B stated the resident had never expressed suicidal ideations prior to the incident. CNA B said that after the incident, Resident #1 said his daughter had dropped him off and left him at the facility therefore he felt like he wanted to die. CNA B revealed that Resident #1 was kept on one-on-one supervision until he was picked up by emergency transport and transported to the hospital. Interview on 10/09/25 at 4:22 PM, the Clinical Unit Manager revealed she and the DON responded to LVN A when he notified them about Resident #1 and the call light around his neck. The Clinical Unit Manager stated that Resident #1 was distraught at the time and stated that no one wanted him and that he was not going to get better. The Clinical Unit Manager said that she and the DON removed all items out of Resident #1's room that could be used to harm himself. The Clinical Unit Manager also stated she and the DON placed Resident #1 on one-on-one supervision until emergency transport arrived to take him to the hospital for a psychiatric evaluation. The Clinical Unit Manager said Resident #1 did not have suicidal ideations or mentioned that he felt like hurting himself prior to the incident. The Clinical Unit Manager revealed the Administrator was responsible for reporting incidents to the State. The Clinical Unit Manager also said that if the Administrator was not available to report to the State, the DON could report to the State when needed. Interview on 10/09/25 at 4:38 PM with the DON revealed that she was notified by LVN A that Resident #1 was stating that he was going to kill himself. The DON stated that she responded and went to Resident #1's room immediately. The DON said that Resident #1 was told by his daughter that he was useless during a visit. The DON said that she talked to Resident #1 calmly and took the things out of his room that could be a harm to him such as cords. The DON said the facility received an order to send Resident #1 out for a psychiatric evaluation. The DON stated the Administrator was responsible for reporting unusual events and she (DON) would be responsible if the Administrator 676317 Page 5 of 6 676317 11/26/2025 The Harrison at Heritage 4600 Heritage Trace Parkway Fort Worth, TX 76244

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was out of the building. The DON stated Resident #1 was picked up by emergency transportation later that day. However, Resident # 1 was placed on one-one-one until emergency transport arrived and the resident did not return from the hospital. Interview on 10/09/25 at 5:28 PM, with the Administrator revealed that she was immediately notified of Resident #1's incident. The Administrator stated , Resident #1 did not appear depressed prior to this incident, and he had not expressed suicidal ideations. The Administrator stated that Resident #1 was placed on one-on-one supervision after the incident and then sent out for a psychiatric evaluation and did not return from the hospital. The Administrator also revealed that a head-to-toe assessment had been completed, and no redness or red marks were found on the resident's neck. The Administrator also stated that after the resident was found, they developed a new assessment which would have the resident placed on one-on-one supervision, would be referred to psychiatric serviced, and sent out for psychiatric evaluation. The Administrator stated they in-serviced immediately on this new policy after Resident #1 was found in his room. The Administrator stated she reviewed the regulations with her upper management, and felt this incident was not reportable. Record review of the facility's current Abuse Prohibition Protocol policy, dated 08/25, revealed the following: .5. The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment. 7. i. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. 676317 Page 6 of 6