Interlochen Health And Rehabilitation Center

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

care plans in the place the regular care plans were, and did the baseline care plans as they would the regular care plans, and they continued to care plan residents from there, so they were not a separate document from the regular care plans. She looked at the state surveyor's computer screen for Resident #1's care plans and acknowledged there were none. She said she had been working with the staff to do the baseline care plans and had asked them how they were giving an acknowledgement form for care plans to people, if there were no care plans. [TF5] An interview on 01/29/26 at 12:04 PM with ADON D revealed he provided the acknowledgement form to Resident #1's family member, who was his responsible party, after

they had met and had a conversation about the resident's plan of care. He said he must have forgotten to put the documentation in, because he was just moving too fast. He said there was no documented baseline care plan, only a verbal one from his meeting with Resident #1's responsible party. He said that was a problem because if it's not documented, you didn't do it, and the care plans contained instructions for the resident's care. He said the baseline care plans were the normal care plans with the information from admission and was a combination of information from the admitting nurse, and he and the DON reviewing

the clinical admission information and medications. He said Resident #1 was the same as the state surveyor observed when he admitted , being groggy sometimes, quiet, a high fall risk, and mostly non-verbal. An interview on 01/29/26 at 5:29 PM with ADON E revealed the baseline care plans were important because they were provided to the residents and families in order for them to know what care the resident was getting. The Regional RN explained the admitting nurses did the admitting assessments and also entered some care plans. Review of the facility's undated, policy Base Line Care Plans reflected Completion and implementation of the baseline care plan within 48 hours [TF6] of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited too [sic] Initial goals based

on admission orders. o Physician orders. o Dietary orders. o Therapy services. o Social services. o PASARR recommendation, if applicable. The baseline care plan will reflect the resident's stated goals and objectives, and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives. This facility will provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: The initial goals of the resident. A summary of the resident's medications and dietary instructions. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Any updated information based on the details of the comprehensive care plan, as necessary.

The medical record will contain evidence that the summary was given to the resident and resident.

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

01/29/2026

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 0656 Level of Harm - Minimal harm or potential for actual harm

return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.Discharge plans in the comprehensive care plan, as appropriate.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

01/29/2026

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

if someone could not stand, or bear weight. She said he was total, meaning he could not do any part of the lift by himself, and sometimes he worked with them on transfers, and sometimes he didn't. She said if they were lifting him with the gait belt, they should have used his pants waistband to steady him, not his arms.

An interview on 01/29/26 at 12:04 PM with ADON D revealed Resident #1 was new, and when he admitted

he thought the resident was unable to bear weight, and had not noticeably changed since his admission.

He said Therapy usually screened new residents very quickly after they admitted , usually the day after the admission, but the lingering icy weather had impacted therapy's staffing, as well. After the nurse did a thorough assessment of the resident, the staff should have used a mechanical lift to get him up, and should never lift someone under the armpits. He said they did in-services and skills check-offs with the CNAs to make sure they knew how to properly transfer residents, and they did cover how to get a resident off the floor. An interview on 01/29/26 at 5:29 PM with the Regional RN and ADON E revealed the Regional RN said there were two or three ways to transfer a man in the situation Resident #1 had been in, and none of them ever involved using the resident's arm. She said they could have pulled the resident's arms out of the sockets. ADON E said lifting a resident the way the CNAs had done, it could cause physical trauma or skin tears. The Regional RN said the staff were trained on how to move a resident, but were currently being trained again. She said it was the ADONs' and nursing management's responsibility to make sure the staff knew how to lift, and how to do it right, and they had done training and skills check-offs on all types of transfers. Review of a CNA Proficiency Audit for CNA A, dated 11/26/25, reflected she performed satisfactorily in one-person assisted, two-person assisted, mechanical lift two-person, and ambulatory resident transfers. Review of a CNA Proficiency Audit for CNA B, dated 11/26/25, reflected she performed satisfactorily in one-person assisted, two-person assisted, mechanical lift two-person, and ambulatory resident transfers. Review of the facility's undated policy Moving a Resident Bed to Chair/ Chair to Bed reflected no mention of what to do when a resident was unable to assist in a transfer, or bear weight. The document did reflect: Purpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: Note: This procedure may require two (2) persons [.] 9. If moving a resident from bed to chair: [.] b. If transferring the resident to a wheelchair: 1. Be sure the wheels are locked; [.] h. Position a gait belt around

the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable i. If

the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn

the resident and sit him or her in the chair. j. If the resident can assist in this procedure, stand on the resident's weak side. (Note: Encourage the resident to use his or her strong side and to assist in the procedure as much as possible.) k. Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident. 1. Instruct the resident to turn so that the back of his or her legs are near the chair. m. Instruct the resident to place his or her hands on the arms of the chair for support. n.

Move with the resident. o. Be sure the resident is all the way back in the chair. [.] Review of the facility's undated Fall Policy reflected: Appendix A: Fall Intervention Methods: Environmental [.] Staff must be trained

in safe transfer techniques and proper use of body mechanics.

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

01/29/2026

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 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 2 halls (Hall 200) reviewed for pest control.1. The facility failed to ensure Hall 200 was free of gnats.2. The facility failed to ensure one room at the south end of the hall was free of gnats.These failures could place residents at risk of infestation of pests and compromise resident health.Findings included: Observation on 01/29/2026 at 9:48 A.M. on the south end of Hall 200 revealed 1 gnat flying around. During an observation and interview on 01/29/2026 at 11:05 A.M. with Resident #2, in her room at the south end of Hall 200, she revealed the gnats had always been an issue. She indicated the gnats were worse, compared to the past. When asked if the gnats bothered her,

she said, oh yeah. Resident #2 said she told staff about the gnats, and it could be a topic of conversation for anyone who came into the room. She said as far as she knew the room had been sprayed. This state surveyor counted 3 gnats around Resident #2, and 5 gnats around the sink in the room. Observation of the sink in the room revealed that sink was clean and had no foul odors. Observation on 01/29/2026 at 12:26 P.M. revealed 1 gnat flying around in the north end of Hall 200. Observation on 01/29/2026 at 12:28 P.M. revealed 1 gnat flying around the nurse's station in Hall 200. During an interview on 01/29/2026 at 1:05 P.M. with LVN I, she revealed she saw gnats and was supposed to tell housekeeping if there were gnats in resident rooms. She said pest control had come and sprayed chemicals and it worked. LVN I said the risk of having gnats was they were not good and could fly into residents' mouths, noses, hair, and in their skin.

During an interview on 01/269/2026 at 2:56 P.M. with LVN J, she said she saw gnats but not in the whole building. She indicated she saw gnats on a meal tray in a resident room and took the meal tray out of resident's rooms when she saw them. LVN J said maybe food (in the resident rooms) was an issue. She said the risk to residents was it might bite the residents or (residents) would not want to eat the food. She said pest control came when called and she reported pest issues to the administrator. During an interview

on 01/29/2026 at 5:45 P.M. with the ADM, she revealed the facility had actively been treating the gnats. She stated the pest control company was recently at the facility and had left treatment for the facility to use to treat the gnats. She said it had been a little better, but it was a known issue and if gnats were seen during rounds the ADM was to notify the (pest control company. Records requested for review on 01/29/2026 at 2:25 P.M. and 02/02/2026 at 2:22 P.M. for the facility's pest control policy and pest control log. The facility only provided the food service department's Insect and Rodent Control policy. A pest control policy for the whole facility and a pest control log was not provided. Record review of the facility's food service department's Insect and Rodent Control policy, dated 2012, reflected: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department.Procedure:1.

Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.2. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents.3. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents.4. Deliveries of food and supplies will be monitored for prevention of insect and rodent access.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet