Health inspection·January 9, 2025

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. Page 1 of 2 676247 676247 01/09/2025 Sandy Lake Rehabilitation and Care Center 1410 E Sandy Lake Rd Coppell, TX 75019

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. 676247 Page 2 of 2