Interlochen Health and Rehab: X-Ray Delay Left Resident in Pain - TX
That sequence of failures is what federal inspectors documented at Interlochen Health and Rehabilitation Center, a nursing facility at 2645 West Randol Mill Road in Arlington, Texas, following a complaint inspection completed September 4, 2025.
The resident at the center of the complaint is identified in inspection records only as Resident 1. A certified nursing assistant noticed her wrist was swelling on Monday, September 1, and reported it to LVN H, the nurse on duty. The nurse practitioner happened to be present at the facility when the report came in. She assessed the resident, ordered an x-ray, and told staff to apply an ice pack. The order was marked stat.
Stat, in clinical practice, means within four hours.
The x-ray did not happen within four hours. It did not happen that day. When the director of nursing came in Tuesday morning, the x-ray had still not been completed. It had only been ordered.
Nobody had called the x-ray company to ask what was happening. Nobody had contacted the nurse practitioner to ask about next steps. Nobody had considered sending the resident out for evaluation.
When inspectors interviewed LVN H on the afternoon of September 4, he said he knew how to enter a stat order correctly in the computer system and knew that stat meant within four hours. He said that if the x-ray company did not arrive within that window, the correct procedure was to call them, and if they did not answer, to report to management. He said he did not explain why none of that happened.
He did say that Resident 1's pain was managed because she had routine Tylenol on her medication schedule.
The director of nursing, interviewed the same afternoon, offered a more candid assessment of what the delay meant. She said Resident 1's arm could have broken further. She said a lot of things could have happened to that arm. She used the word neglect.
The x-ray eventually got done. But when it did, staff imaged the forearm, not the wrist. The swelling and bruising that prompted the entire sequence of events was in the wrist. The director of nursing told inspectors she did not know what caused the delay or why the wrong area was imaged.
The director of nursing said the stat order did not go through completely because staff failed to click a final button in the computer system, the one that sends the image request. Without that click, the order existed in the system but never reached the x-ray company. A stat order with a four-hour window, placed on a holiday Monday, that never actually left the building.
Pain assessment ran into its own separate set of problems.
LVN H told inspectors that Resident 1 was assessed for pain whenever she received her scheduled medications. He acknowledged that the facility's electronic system does not include a field to document pain levels for scheduled medications, only for medications given on an as-needed basis. For scheduled medications, pain assessments would have to be entered manually in progress notes. Inspectors reviewed the records and found the assessments were not consistently there.
Resident 1 is non-verbal. LVN H said he used an app on his phone to communicate with her and that she denied pain. The director of nursing told inspectors that for residents who cannot verbalize pain, nurses are supposed to use a nonverbal pain scale and observe behavior: whether the resident appears depressed, is acting out, is angry. She said pain should be assessed every shift and documented on the treatment administration record. She said if it is not, residents could be in a lot of pain, could become depressed, could develop behavioral problems.
The facility's own pain management policy, reviewed by inspectors, requires nurses to assess physical symptoms of pain, complaints, and daily activities. For non-verbal residents, it specifies use of the PAINAD assessment scale, a standardized tool for measuring pain in people who cannot self-report. If a resident scores between seven and ten on that scale, the policy triggers a formal pain review process.
Whether that scale was used consistently for Resident 1 during the days her wrist was swollen and unimaged is not resolved in the inspection record.
What the inspection record does resolve is that a nurse practitioner saw a bruised, swollen wrist, called it urgent enough to order a stat x-ray, and then the facility's systems, both human and electronic, failed to execute that order in any timely or accurate way. The order did not transmit. The follow-up calls were not made. The escalation to management did not happen. The x-ray that eventually occurred captured the wrong part of the arm. And a non-verbal resident sat with an injury of unknown severity, managed on routine Tylenol, while each of those failures accumulated.
The director of nursing acknowledged the Tramadol was only added the day before inspectors arrived, more than two days after the initial injury was reported.
By the time inspectors conducted their interviews on September 4, the facility had begun corrective steps. Tramadol had been added to Resident 1's pain regimen. The director of nursing said pain should be assessed every shift. Whether those assessments were happening in the days between September 1 and September 4 is one of the questions the inspection record leaves open.
The director of nursing said the risk, in her own words, was neglect. She said a lot of things could have happened to that arm. She did not specify what the x-ray of the forearm ultimately showed, and the inspection record does not say.
Resident 1 remained at the facility. Her wrist had been bruised and swollen for days before anyone confirmed, on film, what was actually wrong with it, and even then, the film was of the wrong place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Interlochen Health and Rehabilitation Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
Interlochen Health and Rehabilitation Center in Arlington, TX was cited for violations during a health inspection on September 4, 2025.
The resident at the center of the complaint is identified in inspection records only as Resident 1.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.