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. (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 02/27/2025 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)