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 Provider Investigation Report dated 07/07/2025 and electronically signed on 07/17/2025 at 11:16 AM 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 (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 07/23/2025 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)