Advanced Health & Rehab Center Of Garland

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

observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for one of five residents (Resident #1) reviewed for physical restraints. The facility failed to ensure Residents #1 had physician orders or a physician assessment for the bolster mattress on her bed. This failure could place residents at risk of not having an environment that was free of restraints which could result in injury.Findings include:

Record review of Resident #1's Face Sheet, dated 09/25/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE REDACTED]. Relevant diagnoses included muscle weakness and unsteadiness on feet.

Record review of Resident #1's Quarterly MDS assessment, dated 7/24/25, reflected she had a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance and an active diagnosis of muscle weakness. Record review of Resident #1's Comprehensive Care Plan, dated 9/25/25, reflected the resident was a fall risk and interventions included a fall mat placed alongside the bed and the bed in a low position. In an observation on 09/25/25 at 8:46 AM, revealed Resident #1 was observed lying on a bolster mattress on her bed. Record review of Resident #1's physician orders, dated 9/25/25, reflected no physician orders for the bolster mattress. In an interview on 09/25/25 at 12:41 PM, ADON A stated hospice provided the resident the equipment. He stated the resident had not had

a fall in a long time. He stated the resident should have had a physician's order for the bolster mattress because staff may not know that she needed it for fall prevention. In an interview on 09/25/25 at 1:39 PM

the Administrator stated she was not a nurse, but she would think a physician's order would be needed for

the equipment since it was needed for her care. She stated she would follow up with the DON and ADON to ensure a physician's order was obtained. Record review of the facility's policy Restraint Free Environment (10/24/22) reflected It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Health & Rehab Center of Garland

1201 Colonel Drive Garland, TX 75043

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

E stated she was the Charge nurse for Resident #5. She was told about the medication administration report for the month of September 2025 for Resident #5, which indicated the resident had received all of his medication from 09/12/25 to 09/19/25; however, the progress notes revealed the resident had refused all medication. She stated they should check off that the medication was administered to the resident after the resident was witnessed taking the medication. She stated they would then place a code that the medication was administered and their initials. She stated if the resident refused the medication, a code would be used indicating the resident refused. She stated she would also notify the RP, the physician, and the ADON. She stated the medication administration had to be charted correctly because if they did not, it could be bad for

the patient. Record review of facility policy, Medication -Treatment Administration and Documentation Guidelines, revised 02/10/2020, revealed To provide a process for accurate, timely administration and documentation of medication and treatments. Verify labels accurately reflect the physician orders on the Medication Administration Record ( MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments 2. Verify administration accuracy by checking the medication with the MAR three (3) times 3. Verify and provide medication or treatment focused assessment i.e. BP. P wound measurements as indicated by manufacturers guidelines or physician orders 4. Administer

the medication according to the physician order 5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Health & Rehab Center of Garland

1201 Colonel Drive Garland, TX 75043

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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

location in their rooms and she repositioned the call lights to be within reach of the residents. She stated

she did not know why the call lights were moved. She stated they normally clipped them on the bed, near

the resident. She stated the residents could not contact anyone if they needed help, if the call lights were not within their reach. She stated they normally made their rounds every two hours to ensure that the call lights were within the resident's reach. In an interview and observation on 09/25/25 at 8:35 AM, CNA C stated she was the CNA for the 100-hall. She was shown pictures of Resident #1 and #2's call light not being within reach of the residents. She stated she had already repositioned the call lights within the residents reach. She stated they checked on the residents at least every two hours to ensure the call lights were within reach of the residents. She stated the call lights needed to be within reach of the residents in case they needed assistance. In an interview on 09/25/25 at 12:20 PM 8:35 AM, RN O stated she was the nurse for the 600-hall. She was shown pictures of Resident #3 and #4's call light not being within reach of

the residents. She stated the call lights needed to be within reach of the resident so they could contact staff if they were in distress. She stated the CNAs and the nurses made rounds almost hourly and they have to ensure the resident's call light was within their reach. In an interview on 09/25/25 at 12:20 PM 8:35 AM, LPN A stated she was the nurse for the 100-hall. She was shown pictures of Resident #1 and #2's call light not being within reach of the residents. She stated the call lights needed to be within reach of the resident so they could contact staff if they needed help. She stated the CNAs and the nurses made rounds almost hourly because they staggered their rounds. She stated one of the tasks when checking on the resident was to ensure the resident's call light was within their reach. She stated staff sometimes forget to do this when they put the resident back in bed. In an interview on 09/25/25 at 12:41 PM, ADON A was shown pictures of Resident #1, #2, #3, and #4's call light not being within their reach. He stated the call lights needed to be within reach of the residents in case they had an emergency. He stated the nursing staff was to check for that every time they made their rounds. He stated he would in-service the staff on call light placement and the need to ensure the call lights are within reach of the resident after assisting the resident and when making their rounds. Record review of the facility's policy on Call Light Response (02/10/21), revealed The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed.

Event ID:

Facility ID:

If continuation sheet