Inspection·September 4, 2025

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for pain management. The facility failed to follow their pain management policy when Resident #1's response to pain medication was not monitored and effectiveness was not recorded.This failure could place residents at risk of uncontrolled pain.Findings included:Record review of Resident #1's admission record, dated 09/04/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with type 2 diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels) and dementia (brain disease that alters brain function and causes a cognitive decline). Record review of Resident #1's BIMS assessment, dated 08/27/2025, revealed a score of 2, indicating severe cognitive impairment. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H revealed, Resident noted with swelling and bruising on the right wrist, with discoloration observed. Per previous report, findings are possibly related to delayed injury from a recent fall. NP assessed resident during unit visit and provided new orders: X-ray 2-view of right hand and application of ice pack BID x 3 days. Safety maintained; resident monitored for pain and further changes.Record review of Resident #1's Event Follow up note, dated 09/01/2025, written by LVN H revealed, in part .New orders: 2 view x-ray to the right wrist Due to pain /bruising and swellingName of MD/NP notified: [Name] NP Date/time of notification: 09/01/2025 12:00 PMName of RP notified: [Name] Date/time of notification: 09/01/2025 12:00. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H at 8:20 PM revealed, Nurse on [shift] following up on X-ray order placed this morning, called X-ray provider, [Provider Name] twice, and received no answer from the receiving end. report given to oncoming nurse to monitor and report on pending stat X RAY to be done.Record review of Resident #1's progress notes, dated 09/01/2025, written at 10:45 PM by LVN G revealed, Resident in bed sleeping with eyes closed after shift report. Respirations even and non-labored. HOB elevated 30-35 degrees. No signs of any respiratory distress or SOB noted. Right wrist swelling and bruising in place as per report received from 0600-2200 (6:00 am - 10:00 pm) shift nurse. No signs or symptoms of any discomfort noted when site lightly palpated. VS- R. 20, O2 Sats 95RA, B/P 133/74, P. 70, T. 97.3. Right wrist elevated to decrease swelling. Resident continues on Ice pack application to sited as ordered while waiting for X-Ray to be done/ report. Bed placed in lowest position with bolsters and floor mat in place for safety. Continue to monitor resident.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 2:34 PM revealed, Resident's right wrist remains swollen. Ice pack applied as ordered for pain and swelling. Nurse followed up with [Provider Name] regarding X-ray order; confirmed X-ray technician scheduled to arrive today for imaging. [RP, Name] was notified and requested ongoing updates on the resident's progress. Safety and comfort maintained. Will continue to monitor.Record review of radiology report, dated 09/02/2025, revealed RIGHT TIBIA(shinbone)/FIBULA(calf bone) SERIES Findings: Examination of the right tibia/fibula demonstrates no evidence for fracture. There are no bony abnormalities. The soft tissues are unremarkable. IMPRESSION: Negative Study.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 10:13 PM revealed X-ray results of the resident's right wrist faxed to NP; findings indicate no fracture. NP recommended continued icing and elevation of the arm on a pillow. New order was received to apply a sling to the right hand while the resident is awake. Safety and comfort maintained. Will continue to monitor.Record review of Resident #1's progress notes, dated Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455835 If continuation sheet Page 2 of 9 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 09/04/2025 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/03/2025, written by LVN G at 4:34 AM revealed, Resident right wrist elevated as tolerated d/t swelling. Bruise intact and clearing. No signs of any discomfort noted when resident wrist assessed. VS- R. 20, O2 Sats 95%RA, B/P 129/77, P. 76, T. 97.4. Bed in lowest position with bolsters in place and floor mat in place and close to bed for safety. Call light in reach.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN B at 9:53 AM revealed resi alert w/ large bruise to R hand. no SOB or acute resp distress observed. N/O received to send resi to ER of [Hospital Name] in [City] for further evaluation and treatment due to large bruise to R hand. VS taken & WNL w/ 129/77 63 19 97.8 97 and BS 128. Routine ice pack + PP admin w/ positive outcome. EMS was called and transported resi out of facility at 10:05am. resi [RP Name] was informed of resi being transported.Record review of Resident #1's progress notes, dated 09/03/2025, written by the DON at 10:09 AM This Called resident [RP], and received call back, regarding swelling to R wrist. This nurse explained the interventions in place, and I thought to believe could be from delayed injury from previous fall. The [family member] explained that [Resident #1] did not have swelling to hand, she was playing around hitting a family member and playing and laughing with family Friday the [family member] requested the resident be sent to ER [Hospital Name] for Further eval. This nurse notified Nurse to send to ER.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN H at 4:45 pm revealed Resident returned from [Hospital Name] with diagnosis of closed fracture distal end of R radius (broken right wrist). Seen by NP during rounds; new orders: Tramadol 50 mg PO BID PRN pain, d/c Tylenol 650 mg, start Tylenol 1 g PO q8h PRN pain. Splint to remain on at all times; sling when OOB; wrist brace and thumb spica splint in place. Resident repeatedly removed dressing and sling; nurse reapplied several times. [Family member] notified of resident's return; verbalized availability for contact, will visit tomorrow. Resident resting in bed; safety and comfort maintained.Record review of hospital x-ray results, dated 09/03/2025, revealed the following: Findings: Discontinuity of the cortex of the central articular surface of the distal radius (wrist) seen on the lateral (side) view only. Nondisplaced fracture (bones remain in alignment) of indeterminate age (unknown if new or old) cannot be excluded. No other fractures. Moderate osteoarthritis (common joint condition that causes pain, stiffness) at the radiocarpal (wrist) join t and first carpometacarpal (base of thumb) joint, No dislocation. No lytic (areas of bond destruction that result in holes) or blastic (areas of abnormal growth) lesions. Impression: Nondisplaced fracture of indeterminate age at the distal radius articular surface.Record review of Resident #1's August 2025 MAR revealed the following:- Tylenol Oral Capsule 325 MG Give 2 tablet by mouth two times a day for Pain -D/C Date-09/03/2025. Administered 09/01/2025, 09/02/2025 and 09/03/2025 for AM and PM doses.- Tylenol Oral Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for headache; pain-mild. Pain level 3. Administered on 09/03/2025 administered prn.- Ice pack to the right hand BID FOR Days /Pain and swelling right wrist two times a day for Pain and swelling Apply to right wrist twice a day for 3 days. Administered on 09/01/2025 for the PM dose, on 09/02/2025, and 09/03/2025 for both AM and PM doses, and on 09/04/2025 for AM dose. - Tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth two times a day for Pain. Administered 09/04/2025 on the AM shift.Record review of Resident #1's pain assessment, dated 09/03/2025, revealed Tylenol 325mg give 2 tabs by mouth BID and prn every 6 hours for headache and mild pain.Record review of Resident #1's August 2025 TAR revealed no pain assessment or follow up for pain medication effectiveness. Record review of Resident #1's order summary revealed the following: Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for headache; pain-mild. Start dated 08/07/2025- Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth two times a day for Pain. Start date 09/04/2025- Keep the Splint on at all times Keep the sling intact when out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455835 If continuation sheet Page 3 of 9 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 09/04/2025 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of bed Wrist Brace and Thumb Spica Splint. Start date 09/03/2025.- Orthopedic Consult to eval and treat closed fracture to distal radius (wrist). Start date 09/03/2025.Record review of intake investigation worksheet priority date 09/03/2025, revealed Resident was sent to hospital on [DATE] and returned same day with a Dx of a hand Fx.Family asked for resident to be sent to hospital due to hand discoloration and swelling on return to the facility the x-ray determined a hand Fx. Still collecting information for investigation. Observation on 09/04/2025 at 10:59 am, in the secure unit revealed Resident #1 was well groomed and dressed sitting up in her w/c at a table in the dining room. Resident #1 was looking at a magazine and did not appear to be in any pain. Resident #1's right arm was in a sling with a plastic bag of ice under the hand. Interview on 09/04/2025 at 11:01 am, MA A stated she did not normally work in the secure unit. She stated she worked yesterday morning in the unit but did not know how Resident #1's injury happened. MA A said Resident #1's hand was swelling, and the nurse already knew about it. She said if she saw any injury or new bruise or swelling on a resident she would report to the nurse immediately. Interview on 09/04/2025 at 11:17 am, LVN B stated she normally works in the secure unit Monday through Friday on the morning shift but was not at work from Friday (08/29/2025) at 2:00pm through Tuesday (09/02/2025). She stated on Wednesday (09/03/2025) she saw a bruise on Resident #1's hand, the x-ray was negative but she was sent out to double check. She said she got an order to send her out, did an assessment and called EMS and the family waited at the hospital. She stated Resident #1 was assessed for pain and has pain medication. LVN B stated Resident #1 was Spanish speaking and used a communication board and she assessed Resident #1's pain by showing an image on her phone and asking if the pain was small, medium or high . LVN B stated if a new injury, swelling or bruise was found she would automatically report it to the DON, Administrator and Doctor if she could not explain the injury or the patient was not able to explain. She stated if there was an order for a stat x-ray they would be there within 4 hours and if not, she would let them know so they could be sent out. Interview on 09/04/2025 at 11:36 AM, CNA C stated she worked over the weekend and did not see any bruising on Resident #1's hand. She said when she came in Monday (09/01/2025), she noticed the bruise and reported to the nurse immediately. Interview on 09/04/2025 at 12:18 PM, the Administrator stated from his understanding it was found Resident #1's hand was swollen. He stated he rounded with the DON yesterday and she brought it to his attention that the RP requested Resident #1 be sent out for an x-ray. The Administrator stated he did see Resident #1's hand before she was sent to hospital and it was swollen with some bruising, but she could move all digits. He stated as he started doing the investigation he realized there were some communication issues between staff and Resident #1's family about what happened. He stated he found out Resident #1's fall was on 08/15/2025, and that was considered a separate incident and could not be tied to the wrist fracture. He stated he had not personally seen the results, but the family said there was a fracture. He said as he started in servicing, asking questions and getting statements, the swelling was found on Monday, a stat x-ray was ordered but the x-ray company never came out. When the x-ray was completed, the x-ray was of the forearm and was negative. He stated the expectation for staff was if a stat x-ray was ordered and not completed within 4 hours they should send the resident out. He said the risk to residents could be continued pain and delay of treatment.Interview on 09/04/2025 at 2:24 PM, the Medical Director stated staff notified him on 09/03/24 that Resident #1 went out and she had a fracture. He stated he was going to round on Resident #1 today. He stated he would order an x-ray, depending on what that shows, would come see the patient, then if something needed to be addressed by orthopedic then send to the emergency room. He stated his expectation for staff was if a stat x-ray was ordered and not done, or if patient was having severe pain then send them out. Interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455835 If continuation sheet Page 4 of 9 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 09/04/2025 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/04/2025 at 2:49 PM, Resident #1's RP stated on 09/02/2025 around 2:30 pm, the nurse called to inform her of Resident #1's bruises on right hand possibly from a fall on the 15th. The RP said, How could she have bruises? ; she did not see any over the weekend when the whole family came to see her. The RP stated she spoke with the DON who said late injuries were found from the fall on the 15th. The RP stated she requested for Resident #1 to go to the hospital and met her there. The RP stated the hospital physician stated the fracture happened at least 48 hours ago and not three weeks ago. The RP said she went back to the facility with a splint. Interview on 09/04/2025 at 3:03 PM, the NP stated on Monday 09/01/2025, when she rounded at lunch, the nurse had notified her about Resident #1's wrist. The NP stated she contacted the DON, ordered an x-ray and the x-ray came back negative. The NP said the Doctor just looked at the results and the fracture was on the side and if they did not do a lateral or 2 view it would be negative. She said if the order was stat, it should be done within 4 hours. She stated if a stat x-ray was not done within that time, staff should contact her or send the resident out. She said Resident #1's pain was managed with Tylenol and ice. She said she changed the pain medication yesterday, to Tramadol twice a day and increased Tylenol.Interview on 09/04/2025 at 3:26 PM, the DON stated on Monday (09/01/2025) Resident #1's wrist was bruised, LVN H did an event note, contacted the NP and got an order for x-ray. The DON stated she came in the next day (Tuesday) and the x-ray was not done but was ordered. She said she did not know what the delay was, but they ended up getting the x-ray done of the forearm and not the wrist. The DON stated it was ordered stat, but the order did not go through all the way because you have to click send image. The DON stated a stat order has a 4 hour window and if it was not completed within that time frame, the nurse should call and see if they can get an ETA and if not and was an emergency, to send the resident out. She said in this case once the x-ray was not done timely, LVN H should have contacted the provider about next steps. She stated the risk was neglect, and Resident #1's arm could have broken further. She stated a lot of things could have happened to that arm. The DON stated Resident #1 was already on Tylenol and Tramadol was ordered yesterday. She said pain should be assessed every shift and should be documented on the TAR . The DON stated if not residents could be in a lot of pain, have depression or behaviors. She stated for residents that could not verbalize pain, nurses were to use a nonverbal scale and to look at their behaviors, to see what they were doing, if they were depressed, acting out or angry. Interview on 09/04/2025 at 4:21 PM, LVN H stated CNA notified him Monday that Resident #1's wrist was swelling. He stated when she reported to him the NP was here, assessed the resident and she ordered the x-ray and ice pack. He stated it was ordered as stat and he does know how to enter the order correctly in the computer. He stated stat meant within 4 hours and if they were not here within that time he should call the x-ray company and if they don't answer he was to report to management. LVN H stated Resident #1's pain was managed because she had routine Tylenol. He stated Resident #1 denied pain and he used an app on his phone to communicate with the resident. He stated Resident #1 was assessed for pain whenever she was administered meds . He stated in the system, if the medication was scheduled it does not have a place to put a pain level, only on prn medications so they document in the progress notes . He stated residents could be in pain if not assessed for pain or the effectiveness of pain medication. Record review of facility policy titled Pain Management, Assessment Scale undated, revealed the following Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribe medications, and comfort measures, and all available resources of the facility. Procedure1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability were included in the Admission/readmission and Weekly Nursing Summary.If a resident is non-verbal, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455835 If continuation sheet Page 5 of 9 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 09/04/2025 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete questions will be a PAINAD assessment .If the MDS QM Pain criteria is met, a Pain SBAR will be triggered .There is no QM criteria for a resident who is non-verbal. If a resident scores 7-10 on the PAINAD scale, then a PAIND SBAR will be triggered. It is directed toward residents who are non-verbal or cannot communicate. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects.PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned.9. Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. 1110 nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain. Event ID: Facility ID: 455835 If continuation sheet Page 6 of 9 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 09/04/2025 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)

F 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to provide or obtain radiology services to meet the need of its residents for 1 of 1 Residents (Resident #1) reviewed for radiology services. The facility failed to correctly order and follow up on stat x-ray. Resident #1 did not get an x-ray for more than 24 hours after a stat x-ray was ordered. The x-ray performed was performed on the leg instead of the wrist.This failure could place residents at risk of delayed treatment, and pain.Findings included:Record review of Resident #1's admission record, dated 09/04/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with type 2 diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels) and dementia (brain disease that alters brain function and causes a cognitive decline). Record review of Resident #1's BIMS assessment, dated 08/27/2025, revealed a score of 2, indicating severe cognitive impairment. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H revealed, Resident noted with swelling and bruising on the right wrist, with discoloration observed. Per previous report, findings are possibly related to delayed injury from a recent fall. NP assessed resident during unit visit and provided new orders: X-ray 2-view of right hand and application of ice pack BID x 3 days. Safety maintained; resident monitored for pain and further changes.Record review of Resident #1's Event Follow up note, dated 09/01/2025, written by LVN H revealed, in part .New orders: 2 view x-ray to the right wrist Due to pain /bruising and swellingName of MD/NP notified: [Name] NP Date/time of notification: 09/01/2025 12:00 PMName of RP notified: [Name] Date/time of notification: 09/01/2025 12:00. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H at 8:20 PM revealed, Nurse on [shift] following up on X-ray order placed this morning, called X-ray provider, [Provider Name] twice, and received no answer from the receiving end. report given to oncoming nurse to monitor and report on pending stat X RAY to be done.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 2:34 PM revealed, Resident's right wrist remains swollen. Ice pack applied as ordered for pain and swelling. Nurse followed up with [Provider Name] regarding X-ray order; confirmed X-ray technician scheduled to arrive today for imaging. [RP, Name] was notified and requested ongoing updates on the resident's progress. Safety and comfort maintained. Will continue to monitor.Record review of radiology report, dated 09/02/2025, revealed RIGHT TIBIA(shinbone)/FIBULA(calf bone) SERIES Findings: Examination of the right tibia/fibula demonstrates no evidence for fracture. There are no bony abnormalities. The soft tissues are unremarkable. IMPRESSION: Negative Study.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 10:13 PM revealed X-ray results of the resident's right wrist faxed to NP; findings indicate no fracture. NP recommended continued icing and elevation of the arm on a pillow. New order was received to apply a sling to the right hand while the resident is awake. Safety and comfort maintained. Will continue to monitor.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN B at 9:53 AM revealed resi alert w/ large bruise to R hand. no SOB or acute resp distress observed. N/O received to send resi to ER of [Hospital Name] in [City] for further evaluation and treatment due to large bruise to R hand. VS taken & WNL w/ 129/77 63 19 97.8 97 and BS 128. Routine ice pack + PP admin w/ positive outcome. EMS was called and transported resi out of facility at 10:05am. resi [RP Name] was informed of resi being transported.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN H at 4:45 pm revealed Resident returned from [Hospital Name] with diagnosis of closed fracture distal end of R radius (broken right wrist). Seen by NP during rounds; new orders: Tramadol 50 mg PO BID PRN pain, d/c Tylenol 650 mg, start Tylenol 1 g PO q8h PRN pain. Splint to remain Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455835 If continuation sheet Page 7 of 9 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 09/04/2025 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)

F 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on at all times; sling when OOB; wrist brace and thumb spica splint in place. Resident repeatedly removed dressing and sling; nurse reapplied several times. [Family member] notified of resident's return; verbalized availability for contact, will visit tomorrow. Resident resting in bed; safety and comfort maintained.Record review of hospital x-ray results, dated 09/03/2025, revealed the following: Findings: Discontinuity of the cortex of the central articular surface of the distal radius (wrist) seen on the lateral (side) view only. Nondisplaced fracture (bones remain in alignment) of indeterminate age (unknown if new or old) cannot be excluded. No other fractures. Moderate osteoarthritis (common joint condition that causes pain, stiffness) at the radiocarpal (wrist) join t and first carpometacarpal (base of thumb) joint, No dislocation. No lytic (areas of bond destruction that result in holes) or blastic (areas of abnormal growth) lesions. Impression:Nondisplaced fracture of indeterminate age at the distal radius articular surface.Record review of intake investigation worksheet priority date 09/03/2025, revealed Resident was sent to hospital on [DATE] and returned same day with a Dx of a hand Fx.Family asked for resident to be sent to hospital due to hand discoloration and swelling on return to the facility the x-ray determined a hand Fx. Still collecting information for investigation. Observation on 09/04/2025 at 10:59 am, in the secure unit revealed Resident #1 was well groomed and dressed sitting up in her w/c at a table in the dining room. Resident #1 was looking at a magazine and did not appear to be in any pain. Resident #1's right arm was in a sling with a plastic bag of ice under the hand. Interview on 09/04/2025 at 11:17 am, LVN B stated she normally works in the secure unit Monday through Friday on the morning shift but was not at work from Friday (08/29/2025) at 2:00pm through Tuesday (09/02/2025). She stated on Wednesday (09/03/2025) she saw a bruise on Resident #1's hand, the x-ray was negative but she was sent out to double check. She said she got an order to send her out, did an assessment and called EMS and the family waited at the hospital. She stated if there was an order for a stat x-ray they would be there within 4 hours and if not, she would let them know so they could be sent out. Interview on 09/04/2025 at 12:18 PM, the Administrator stated from his understanding it was found Resident #1's hand was swollen. He stated he rounded with the DON yesterday and she brought it to his attention that the RP requested Resident #1 be sent out for an x-ray. The Administrator stated he did see Resident #1's hand before she was sent to hospital and it was swollen with some bruising, but she could move all digits. He stated as he started doing the investigation he realized there were some communication issues between staff and Resident #1's family about what happened. He stated he found out Resident #1's fall was on 08/15/2025, and that was considered a separate incident and could not be tied to the wrist fracture. He stated he had not personally seen the results, but the family said there was a fracture. He said as he started in servicing, asking questions and getting statements, the swelling was found on Monday, a stat x-ray was ordered but the x-ray company never came out. When the x-ray was completed, the x-ray was of the forearm and was negative. He stated the expectation for staff was if a stat x-ray was ordered and not completed within 4 hours they should send the resident out. He said the risk to residents could be continued pain and delay of treatment. Interview on 09/04/2025 at 2:24 PM, the Medical Director stated staff notified him on 09/03/24 that Resident #1 went out and she had a fracture. He stated he was going to round on Resident #1 today. He stated he would order an x-ray, depending on what that shows, would come see the patient, then if something needed to be addressed by orthopedic then send to the emergency room. He stated his expectation for staff was if a stat xray was ordered and not done, , or if patient was having severe pain then send them out. Interview on 09/04/2025 at 3:03 PM, the NP stated on Monday 09/01/2025, when she rounded at lunch, the nurse had notified her about Resident #1's wrist . The NP stated she contacted the DON, ordered an x-ray and the x-ray came back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455835 If continuation sheet Page 8 of 9 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 09/04/2025 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)

F 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete negative. The NP said the Doctor just looked at the results and the fracture was on the side and if they did not do a lateral or 2 view it would be negative. She said if the order was stat, it should be done within 4 hours. She stated if a stat x-ray was not done within that time, staff should contact her or send the resident out. She said Resident #1's pain was managed with Tylenol and ice. She said she changed the pain medication yesterday, to Tramadol twice a day and increased Tylenol. Interview on 09/04/2025 at 3:26 PM, the DON stated on Monday (09/01/2025) Resident #1's wrist was bruised, LVN H did an event note, contacted the NP and got an order for x-ray. The DON stated she came in the next day (Tuesday) and the x-ray was not done but was ordered. She said she did not know what the delay was, but they ended up getting the x-ray done of the forearm and not the wrist. The DON stated it was ordered stat, but the order did not go through all the way because you have to click send image. The DON stated a stat order has a 4 hour window and if it was not completed within that time frame, the nurse should call and see if they can get an ETA and if not and was an emergency, to send the resident out. She said in this case once the x-ray was not done timely, LVN H should have contacted the provider about next steps. She stated the risk was neglect, and Resident #1's arm could have broken further. She stated a lot of things could have happened to that arm. Interview on 09/04/2025 at 4:21 PM, LVN H stated CNA notified him Monday that Resident #1's wrist was swelling. He stated when she reported to him the NP was here, assessed the resident and she ordered the x-ray and ice pack. He stated it was ordered as stat and he does know how to enter the order correctly in the computer. He stated stat meant within 4 hours and if they were not here within that time he should call the x-ray company and if they don't answer he was to report to management. He stated the risk was they would not know what the injury was and could delay care. The facility did not provide a policy on x-ray services by the time of exit. Event ID: Facility ID: 455835 If continuation sheet Page 9 of 9