Health inspection·February 27, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 3 (Resident #1) residents reviewed for Care Plans. The facility failed to ensure Resident #1's bed was in the lowest position and ensure his bedside table was in a safe location to assist in fall prevention. These failures could place residents at risk of injury. Findings include: Record review of Resident #1's Face Sheet, dated 02/27/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia (cognitive decline), and muscle weakness. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a BIMS score of 07 (severe cognitive impairment). For ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. For active diagnosis it reflected muscle weakness and lack of coordination. Record review of Resident #1's Quarterly Care Plan, dated 02/13/25, reflected the resident had a history of falls and interventions were to provide a clutter free area, and bed in low position. Record review of Resident #1's progress notes dated 02/12/25, revealed the resident had a fall. An observation on 02/27/25 at 08:10 AM, revealed Resident #1 lying on his bed. He had a fall mat placed alongside his bed. His bed was not lowered to the lowest position and the bed side table was placed alongside his bed and not in an area that allows the resident to safely reach items on the bedside table. In an interview and observation on 02/27/25 at 08:12 AM, LVN J stated Resident #1 was a fall risk and his bed needed to be lowered to the lowest position and his living area needed to be free of any hazards. She stated the risk of the bedside table being placed alongside his bed could result in a form of restraint and was a fall risk for the resident. Page 1 of 2 676247 676247 02/27/2025 Sandy Lake Rehabilitation and Care Center 1410 E Sandy Lake Rd Coppell, TX 75019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/27/25 at 10:43 AM, Resident #1's family member stated she resided in the room with the resident. She stated ever since the resident had a fall, she preferred his bed to be in a low position. She stated the only time the resident's bed was in a raised position, was when he was receiving incontinent care. In an interview on 02/27/25 at 11:43 AM, the DON stated the resident, and his family member raises the bed. She stated the risk of the resident's bed not being in the lowest position and the bedside table not being in a safe location could result in the resident having a fall and injuring himself. 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