Health inspection·July 23, 2025

F 0610 Respond appropriately to all alleged violations. 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 report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 3 residents (Resident #1) reviewed for reporting allegations, in that: The facility failed to submit a provider investigation report an injury of unknown origin for Resident #1 to the State Agency within 5 working days of the incident, which occurred on 07/09/25. This failure placed residents at risk for further abuse and neglect due to delayed investigation.Findings included: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] after undergoing the procedure Closed Reduction Percutaneous Pinning Right Hip (surgical procedure to treat a femoral neck fracture; realignment of broken bone fragments in the right hip without making a large incision followed by stabilizing the fracture with screws or pins inserted through small punctures). Resident #1 was diagnosed with Right closed Femoral neck fracture (A break in the femoral neck (the part of the thigh bone just below the hip joint) on the right side of the body, without any open wound (closed fracture)). Resident #1 also had past medical diagnoses of Alzheimer's disease (progressive brain disorder that gradually impairs memory, thinking, and behavior), Vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), hypertension (condition where the force of blood against an artery wall is consistently too high), Alzheimer's dementia with behavioral disturbance (neuropsychiatric symptoms or behavioral and psychological symptoms of dementia that can include agitation, anxiety, depression, aggression, apathy, and psychosis alongside the cognitive decline), osteoporosis (condition that weakens bones, making them more susceptible to fractures), and osteoarthritis (degenerative joint disease that occurs when the protective cartilage cushioning the ends of bones wears down over time). Record review of Resident #1's MDS (a set of standardized assessments done on admission, quarterly, and with a significant change of condition, on each resident) dated 07/11/2025 revealed Resident #1's BIMS (test that is used to get a quick snapshot of how well an individual is functioning cognitively at the moment. A BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance) score was noted to be 04/15 indicating severe cognitive impairment. Resident #1 required reminders, cues, and supervision in planning, organizing, and correcting daily routines as decision making ability was poor. Resident #1 was at risk for falls, impaired gait, balance, impaired cognition, wandering since his admission. Record review of the indicated an allegation of neglect had been reported to the state agency on 07/07/2025 at 9:30 AM, that was received on 07/09/2025 at 11:53 AM, regarding Resident #1. Per [state agency database] search, the provider investigation report was not submitted until 07/17/25, past the 5-day timeframe. Record review of Progress Residents Affected - Few Page 1 of 2 455835 455835 07/23/2025 Interlochen Health and Rehabilitation Center 2645 West Randol Mill Rd Arlington, TX 76012

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notes, written by LVN A, revealed the incident occurred on 07/06/2025 at 11:30 AM and involved Resident #1's right hip, which was fractured after an unwitnessed fall. Resident #1 was reported to be found sitting on the floor of the secured unit in the dining room with a chair behind him. The resident was assessed by LVN A and given pain medication from a standing order of Tylenol Extra Strength 500 mg one tablet after reporting he was at a pain level of 02/10. The resident was not able to say what happened other than I think I fell. NP B was notified at 11:56 AM who ordered a STAT x-ray to bilateral hips. X-ray tech noted to be in building at 2:46 PM on 07/06/2025 when the x-ray was taken and results received at 9:42 PM on 07/06/2025 that indicated no fractures seen. Progress notes revealed that neuro checks were completed throughout the afternoon and evening of 07/06/2025 until 10:05 PM, resuming on 07/07/2025 at 6:02 AM. On 07/07/2025 at 07:30 AM LVN C noticed Resident #1 with facial grimacing and his left foot turned outward as he was being pushed in a manual wheelchair by a CNA. LVN C notified NP B that resident was having pain and was being sent to emergency room for further evaluation of bilateral hips. Transfer Notification note dated 07/07/2025 at 8:15 AM indicated Resident #1 was transferred to the hospital by ambulance at 8:30 AM for further evaluation. Follow up on resident status noted to be on 07/09/2025 at 12:14 PM, when facility contacted family and was informed the resident had received surgery. Resident #1 returned and readmitted to the facility on [DATE] in the evening. On 07/22/2025 at 2:10 p.m., in an interview the Administrator revealed that he was responsible for sending the reports to the CII provider number or submitting directly to TULIP. The Administrator revealed that the DON or one of the Regional Resource personnel would be responsible for timely reporting of an incident if he were unavailable. The Administrator stated that he is responsible not only for the timely reporting, but for also ensuring the Provider Investigation Report is submitted timely. The Administrator stated reporting was within 2 hours of an injury of unknown origin, allegation of abuse, neglect, or misappropriation being made, and that the Provider Investigation Report was due 5 days from the date of reporting. The Administrator stated that the risks of not reporting timely could be delay of care, delayed reporting, or potential continuation of abuse or neglect. Record review of the facility's Abuse policy revised 03/29/2028 revealed in part: .it is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .injuries of unknown origin .and to ensure that all alleged violations .are reported immediately to the Administrator, DON and/or Abuse Prevention Coordinator .will also be reported to the HHSC . Review of Provider Letter PL 2024-14 (Replaces PL 2019-17), issued 08/29/2024, revealed, .report the investigation findings within five working days from the initial report to HHSC . 455835 Page 2 of 2