Health inspection·April 27, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to ensure to ensure resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 8 residents (Resident #58) observed for physical restraints. Residents Affected - Few Resident #58 failed to have physician orders for a scoop mattress for fall prevention. This failure placed Resident #58 at risk of getting injured because of attempting to get out of bed. Findings include: Review of Resident #58's Face Sheet, dated 04/26/23, revealed she was an 85 -year-old female admitted on [DATE]. Relevant diagnoses included Dementia (loss of brain function), Psychosis (hallucinations), and Osteoporosis (bone disease). Review of Resident #58's MDS, dated [DATE] stated she was not cognitively intact with a BIMS score of 03. She required extensive assistance of two person for bed mobility, toilet use, and personal hygiene. Further review of the MDS did not address falls or restraints. Record review of Resident #58's Comprehensive Care Plan, dated 04/26/23 revealed the resident was at risk for falls and had experienced a fall as recently as 04/09/23, because of her attempting to get out of bed. The interventions included call light being in reach, wearing appropriate footwear, and lowering bed to its lowest position. Further review of the care plan did not address a Scoop mattress. Record review of Resident #58's orders, dated 04/26/23 revealed Physician Orders dated 04/11/23 for an Air Mattress (no other description provided). Observation on 04/26/23 at 1:30 PM revealed Resident #58 lying in bed sleeping and she was observed laying on a Specialty low air-loss mattress with a scoop feature x 4 around the bed. The mattress was dark blue in color. Observation and interview on 04/26/23 at 1:35PM with LVN A, revealed she observed Resident #58's mattress and stated the resident had orders for an air mattress and she thought maybe someone from Hospice may have brought in the mattress because of pressure ulcers. She stated the resident did have a (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 5 Event ID: 675453 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 675453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Collinwood Nursing and Rehabilitation 3100 S Rigsbee Rd Plano, TX 75074 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)