Inspection·March 13, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #32) reviewed for infection control. Residents Affected - Few LVN A failed to put on Personal Protective Equipment (PPE) while administering medication via feeding tube to Resident #32, who was on Enhanced Barrier Precaution (EBP). This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident#32's face sheet, dated 3/12/2025, revealed resident was an [AGE] year-old female admitted on [DATE] with diagnoses of spondylosis of cervical region (wear and tear of the spinal disks), chronic obstructive pulmonary disorder, gastrostomy status, and muscle weakness. Review of Resident#32's physician orders, dated 10/11/2024, revealed there was an order for Enhanced Barrier Precaution every shift due to feeding tube status. Review of Resident #32's care plan, dated 4/15/2024, showed that the resident was care planned for Enhanced barrier precaution. One of the interventions included gown and gloves should be worn when enteral feeding care occurs. Observation on 3/12/2025 at 08:24am, LVN A went in Resident#32's room to administer medication via enteral feeding tube without putting on a gown. She only put on gloves after performing hand hygiene. There was an EBP sign on Resident#32's door. In an interview on 3/12/2025 at 09:11am, LVN A stated that she forgot to put on a gown before administering medication for Resident#32. She stated the risk of not putting on personal protective equipment (PPE) was the spread of infection to staff and residents. In an interview on 3/13/2025 at 1:16pm, DON stated that staff should be mindful and look at their assigned residents for the day to determine which residents need EBP in order to adhere to it. She stated the risk of not following EBP was exposing self to different bodily fluids and infection. She stated since December, she has provided two in-service trainings on EBP. She stated she expected her staff to adhere to infection control policy and procedure. (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 2 Event ID: 455835 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 455835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Interlochen Health and Rehabilitation Center 2645 West Randol Mill Rd Arlington, TX 76012 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)