Interlochen Health And Rehabilitation Center

F 0695

Provide safe and appropriate respiratory care for a resident when needed.

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 reviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 (Resident #2) residents reviewed for respiratory care. The facility failed to ensure there were cautionary and safety signs indicating the use of oxygen outside Resident #2's room where oxygen was used. These failures placed the residents at increased risk of injury due to fire hazards.Record Review of Resident #2's admission Record dated 09/04/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with a primary diagnosis of Cerebral Infarction(-stroke), and secondary diagnosis of Chronic Respiratory Failure with Hypoxia (condition where the lungs do not function properly) and Tracheostomy status (Presence of tracheostomy in which a hole is made in the front of the neck to the windpipe, known as the trachea, which

a tube is placed to keep it open for breathing).Record Review of Resident #2's Order Summary Report dated 09/04/2025 revealed order for 2 LPM via nasal cannula when trach is capped during the day, oxygen via trach daily every day shift for oxygen related to Chronic Repository Failure with Hypoxia. During an

observation and interview on 09/04/2025 at 09:52 AM with Resident #2 revealed she was sitting up on the side of bed, wearing oxygen via nasal cannula connected to an oxygen concentrator running at 2 LPM and Tracheostomy capped off. She did not voice any concerns about her oxygen intake. There was no sign outside her room indicating oxygen use. Interview on 09/04/2025 at 2:11 PM with ADON revealed there was not a set individual responsible for making sure oxygen signage was posted on Resident #2's door. He stated the risk of not having oxygen in use signage was so no one will blow up and not to mix and match chemicals. The importance of oxygen in use signage was to let others know which residents have oxygen.

Interview on 09/04/2025 at 3:36 PM with DON revealed, the DON and ADON are responsible for ensuring oxygen in use signage was placed on the Resident's door, to alert staff not to use petroleum jelly around her nose and nothing flammable. The risk was possible harm to the resident. Review of facility's policy and procedure titled, Oxygen Administration undated revealed; 11. Place No SMOKING signs in area when oxygen was administered and stored. Store oxygen cannister in areas free of flammable substances. Avoid

the use of electrical appliances in the area of oxygen use as well .

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet