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 on
observations, interviews, and record reviews, the facility failed to ensure that residents' bed was free from
any physical or chemical restraints imposed for purposes of discipline or convenience for 2 (Resident #1
and Resident #2) of 5 residents reviewed for physical restraints,
Residents Affected - Some
The facility failed to obtain physician orders or a physician assessment as of 01/08/25 for Residents #1 and
Resident #2 for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention.
This failure could prevent residents from having an environment that was free from any physical or chemical
restraints.
Findings included:
Record review of Resident #1's Face Sheet, dated 01/09/25, reflected he was an [AGE] year-old male
admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia, and muscle weakness.
Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he
had a Brief Interview for Mental Status (BIMS) score of 03, ( score of 0-7 indicates severe cognitive
impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally
dependent for assistance.
Record review of Resident #1's physician orders, dated 01/09/25, reflected no physician orders for a scoop
mattress.
An observation on 01/09/25 at 09:00 AM revealed Resident #1 had a scoop mattress on his bed.
Record review of Resident #2's Face Sheet, dated 01/09/25, reflected he was a [AGE] year-old male
admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, history of falls, and muscle
weakness.
Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he
had a Brief Interview for Mental Status (BIMS) score of 01, (score of 0-7 indicates severe cognitive
impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally
dependent for assistance.
(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 2
Event ID:
676247
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
676247
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sandy Lake Rehabilitation and Care Center
1410 E Sandy Lake Rd
Coppell, TX 75019
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 0604
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident #2's physician orders, dated 01/09/25, reflected no physician orders for a scoop
mattress.
An observation on 01/09/25 at 09:00 AM revealed Resident #2 had a scoop mattress on his bed.
An interview on 01/09/25 at 10:00 AM, LVN Y stated that she had been at the facility for 6 months and she
had known Resident #1 and Resident #2 to both have a scoop mattress while she had been at the facility.
She stated she was unsure if Resident #1 was a fall risk, but she was sure Resident #2 was a fall risk. She
stated both residents should have physician orders for use of the scoop mattress. She stated she reviewed
both residents' physician orders on 01/09/25, and no physician orders were found for the residents. She
stated she had communicated this information to the DON for further action. She stated the risk of the
residents not having physician orders for the scoop mattress could result in them injuring themselves.
In an interview on 01/09/25 at 10:00 AM, the DON stated LVN Y had brought to her attention that Resident
#1 and Resident #2 did not have physician orders for the scoop mattresses. She stated that physician
orders were needed for both residents because the residents could injure themselves falling out of their
bed. She stated she had already gotten physician orders for Resident #2 on 01/09/25 from her physician
and was attempting to contact Resident #1's physician so that they could obtain physician orders for the
resident to have the scoop mattress.
The facility's policy Fall Management System (12/2023) reflected It is the policy of this facility to provide an
environment that remains as free of accident hazards as possible. It is also the policy of this facility to
provide each resident with appropriate assessment and interventions to prevent falls and to minimize
complications if a fall occurs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676247
If continuation sheet
Page 2 of 2
