Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sandy Lake Rehabilitation And Care Center during CMS and state inspections, most recent first.
A nurse failed to accurately assess a resident with dementia and a history of multiple falls as a high fall risk, instead documenting them as low risk on two occasions. The resident required substantial assistance and had significant cognitive and physical impairments. The care plan included fall prevention interventions, but staff did not consistently implement them, and some were unaware of the resident's fall history. The nurse admitted to needing more training on the assessment tool, and leadership confirmed the assessments were inaccurate, resulting in insufficient fall prevention measures.
Three residents with significant ADL needs and fall risks were found with their call lights out of reach, preventing them from obtaining assistance as required by their care plans and facility policy. Staff confirmed that call lights should have been accessible to residents at all times.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unassisted by exiting through the front door while staff were distracted, crossing a busy intersection before being found by a pedestrian and returned by staff. The resident had been identified as an elopement risk, but supervision and door security measures were not effectively implemented, resulting in the resident's elopement.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a history of falls. The resident's bed was not consistently kept in the lowest position, and the bedside table was placed in a hazardous location, contrary to the facility's fall management policy. Staff acknowledged the potential fall risk, highlighting a deficiency in adhering to established safety protocols.
The facility failed to obtain physician orders for scoop mattresses used by two residents with severe cognitive impairments and total dependence on assistance. Observations revealed the use of these mattresses without proper medical justification, as confirmed by an LVN and the DON, who acknowledged the oversight.
A resident with COPD did not receive proper respiratory care as their nasal cannula was improperly stored on top of the oxygen concentrator without being bagged, contrary to facility policy. Staff interviews confirmed the expectation for nasal cannulas to be bagged to prevent infection, highlighting a lapse in adherence to respiratory equipment maintenance protocols.
A facility failed to maintain proper infection control when a resident's foley catheter bag was found touching the floor, contrary to policy. The resident, with a neurogenic bladder and at risk for UTIs, had their catheter bag improperly placed, which was acknowledged by an LVN and the ADON as an infection control issue.
A resident sustained a leg fracture after being transported in a wheelchair without footrests by the Director of Therapy, who failed to report the incident. The injury was not discovered until days later when the resident complained of pain, leading to a delay in medical intervention.
A resident sustained a leg fracture after the Director of Therapy failed to use the footrest during wheelchair transport, causing the resident's leg to get caught. The incident was not reported immediately, delaying treatment. The resident, who required moderate assistance, experienced pain and was diagnosed with a fracture days later. The DOT was terminated for neglecting safety protocols and failing to report the incident.
The facility failed to maintain a clean and homelike environment, with surveyors observing unclean conditions in 12 resident rooms and common areas. Handrails had dark stains, and rooms had dust and dirt on air conditioning units and vents. Bathrooms had dirt and stains, with some shower curtains stained. Housekeeping staff were not consistently following cleaning procedures, and the Administrator acknowledged the need for improvement.
The facility failed to maintain an effective Infection Prevention and Control Program, leading to deficiencies in hand hygiene and cross-contamination. A CNA did not change gloves or sanitize hands during incontinent care, an RN improperly brought test strips into a resident's room, and a medication aide neglected hand hygiene during medication administration. Additionally, an RN and CNA did not sanitize hands between glove changes during wound care, risking cross-contamination.
A resident with a neuromuscular bladder dysfunction was not provided a privacy bag for his catheter, despite a physician's order and facility policy requiring it. Observations and staff interviews confirmed the catheter bag was visible, potentially causing embarrassment. The facility's policy mandates privacy bags to maintain resident dignity.
Two residents with COPD in an LTC facility were found with improperly stored respiratory equipment, including a nebulizer mask and nasal cannula, which were not bagged when not in use. This failure to follow infection control practices was confirmed by an LVN and acknowledged by the DON and ADON, who stated that the facility's policy requires such equipment to be bagged to prevent contamination.
A resident with contractures in her hands was not provided with appropriate adaptive equipment for drinking, leading to a spill and scald injury. The resident was served hot coffee in a handle-free tumbler, which she could not grasp, resulting in the spill. The facility failed to provide a cup with handles as indicated in the care plan, and staff were unaware of any special equipment available for the resident.
Failure to Accurately Assess and Address Fall Risk
Penalty
Summary
Nurses at the facility failed to demonstrate competency in assessing fall risk for a resident with a complex medical history, including dementia, multiple falls, and a recent hip fracture. The resident was admitted for hospice care and had diagnoses such as narcotic poisoning, vascular dementia, contractures, and chronic pain. Despite a documented history of multiple falls and significant physical and cognitive impairments, the resident was repeatedly assessed as a low fall risk by an LVN using the Morse Fall Scale on two separate occasions. These assessments did not accurately reflect the resident's condition or history, as the resident required substantial assistance with mobility and activities of daily living and was not aware of his own abilities. The care plan for the resident identified him as being at risk for falls due to medication use, cognitive impairment, vision issues, weakness, and a history of falls. Interventions included close monitoring, keeping the bed in the lowest position, ensuring the call light and personal items were within reach, and providing a clutter-free environment. However, observations revealed that the resident's bed was not always kept in the lowest position, and staff were not consistently aware of the resident's fall history. Additionally, the LVN responsible for the fall risk assessments admitted to needing more training on the assessment tool and acknowledged that the assessments were inaccurate. Interviews with facility staff, including the DON and the administrator, confirmed that the assessments were not completed accurately and that the resident should have been identified as a high fall risk. The facility's policies required accurate identification of fall risk and individualized care planning, but these were not followed in this case. The failure to accurately assess and document the resident's fall risk led to insufficient interventions being implemented for the resident's safety.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required by their care plans and facility policy. Observations revealed that one resident's call light was on the floor and out of reach while he was lying in bed, despite his need for extensive assistance and his status as a fall risk. Another resident, who also required extensive assistance and had a history of falls, was found with his call light pad under the bed and out of reach. This resident reported being unable to contact staff for help when he was wet earlier in the morning. A third resident, who required supervision or touching assistance and was a fall risk, was heard calling for help from his room; his call light was found hanging on the wall, wrapped around an air freshener, and not accessible to him. Staff interviews confirmed that the call lights should have been placed within reach of the residents, in accordance with their care plans and the facility's policy. Staff acknowledged that the improper placement of call lights could prevent residents from alerting staff when assistance was needed. The facility's policy specifically required that call lights be placed within reach of residents when staff leave the room.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of wandering was able to elope from the facility. The resident, who had diagnoses including Alzheimer's disease, dementia, and senile degeneration of the brain, was assessed as an elopement risk and had demonstrated exit-seeking behaviors. On the day of the incident, the resident independently propelled himself in a wheelchair out of the facility's front entrance and crossed a busy intersection with multiple lanes of traffic before being found by a pedestrian and returned to the facility by staff. At the time of the event, the lobby area was busy with residents and staff, and a vendor had entered the building with another resident. The receptionist was engaged in conversation with the vendor and did not notice the resident approaching or exiting through the door. The resident was able to leave the building unassisted because the door was not properly secured after the vendor's entry, and staff did not observe the resident's departure. The facility had identified the resident as an elopement risk, with care plans and assessments noting his cognitive deficits, history of wandering, and need for supervision, but these measures were not effectively implemented to prevent the elopement. Interviews with staff and review of facility policies revealed that procedures were in place for monitoring elopement risk residents, including the use of elopement binders, regular rounding, and staff education on elopement prevention. However, on the day of the incident, these procedures were not adequately followed, as the resident was able to exit the facility without detection. The failure to provide adequate supervision and ensure the security of exit doors directly led to the resident's elopement.
Failure to Implement Comprehensive Care Plan for Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, a male with severe cognitive impairment, unsteadiness on feet, dementia, and muscle weakness, was totally dependent on assistance for activities of daily living such as transfers, toileting, and bathing. Despite having a history of falls, the care plan did not adequately address fall prevention measures, as evidenced by the resident's bed not being in the lowest position and the bedside table being placed in a potentially hazardous location. Observations and interviews revealed that the resident's bed was not consistently maintained in the lowest position, which was a preference expressed by the resident's family member to prevent falls. The facility's policy on fall management emphasized maintaining an environment free of accident hazards, yet the resident's living area was not arranged to minimize fall risks. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged the potential fall risk posed by the bed and bedside table arrangement, indicating a failure to adhere to the facility's fall management policy.
Failure to Obtain Physician Orders for Scoop Mattresses
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints without proper medical justification. Specifically, the facility did not obtain physician orders or conduct a physician assessment for the use of scoop mattresses for two residents, both of whom had severe cognitive impairments and were totally dependent on assistance for activities of daily living. These residents were observed to have scoop mattresses on their beds without the necessary physician orders, which is a requirement for such interventions. The deficiency was identified through observations, interviews, and record reviews. An LVN confirmed that both residents had been using scoop mattresses during her tenure at the facility, but no physician orders were found in their records. The DON acknowledged the oversight and confirmed that physician orders were needed to prevent potential injuries from falls. The facility's policy on fall management emphasizes the need for appropriate assessments and interventions to prevent falls, which was not adhered to in this case.
Improper Storage of Nasal Cannula for Resident with COPD
Penalty
Summary
The facility failed to provide proper respiratory care for a resident diagnosed with chronic obstructive pulmonary disease (COPD), who required oxygen therapy. The deficiency was identified when the resident's nasal cannula was observed to be improperly stored on top of the oxygen concentrator and not bagged when not in use. This improper storage was confirmed during an observation when the resident was not in her room, and the nasal cannula was found hanging on the oxygen concentrator without a protective bag. Interviews with staff, including a CNA and an RN, revealed that the nasal cannula should have been placed in a plastic bag to maintain cleanliness and prevent respiratory infections. The CNA admitted to placing the nasal cannula on top of the bed while searching for a plastic bag, and the RN confirmed the need for bagging the nasal cannula to prevent infection. The Director of Nursing (DON) and the Administrator both acknowledged the expectation for staff to ensure nasal cannulas are bagged when not in use, as per the facility's policy on respiratory equipment maintenance.
Infection Control Deficiency: Foley Catheter Bag Handling
Penalty
Summary
The facility failed to maintain an infection control program, as evidenced by the improper handling of a foley catheter bag for a resident with neuromuscular dysfunction of the bladder. On the date of observation, the resident's foley catheter bag was found touching the floor, which is against the facility's policy designed to prevent contamination and infection. The resident, who had been admitted with a neurogenic bladder and was at risk for urinary tract infections, mentioned that the catheter was usually hung on the side of the bed. During the observation, a Licensed Vocational Nurse (LVN) acknowledged the error and adjusted the bed height to prevent the catheter bag from touching the floor. The Assistant Director of Nursing (ADON) also confirmed that the catheter bag should not have been on the floor, recognizing it as an infection control issue. The facility's policy explicitly states that the drainage bag should not be placed on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infections.
Failure to Notify Physician of Resident Injury
Penalty
Summary
The facility failed to notify the physician of an accident that resulted in an injury requiring medical intervention for a resident. The incident involved the Director of Therapy (DOT) transporting the resident in a wheelchair without footrests, leading to the resident's left leg getting caught and resulting in a fracture. The injury was not discovered until several days later when the resident complained of pain, and an x-ray confirmed the fracture. The resident, who was cognitively intact and required moderate assistance for activities of daily living, did not report pain immediately following the incident. Progress notes indicated no complaints of pain until the resident informed a nurse practitioner, who then ordered an x-ray. The delay in reporting the incident and the injury resulted in the resident not receiving immediate medical attention, which could have led to further damage. Interviews with staff revealed that the DOT did not report the incident until several days later, and the resident's complaints of pain were not adequately addressed until the weekend following the incident. The facility's policy required timely notification of changes in a resident's condition, which was not adhered to in this case, leading to the deficiency.
Failure to Use Wheelchair Footrest Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices, leading to an accident involving a resident. The incident occurred when the Director of Therapy (DOT) transported the resident without utilizing the footrest on her wheelchair. As a result, the resident's sneakers gripped the floor, causing her left leg to get caught under the wheelchair, leading to a fracture in her left leg. The resident, who was cognitively intact and required moderate assistance for activities of daily living, experienced pain and was later diagnosed with a fracture after an x-ray was conducted. Interviews revealed that the DOT did not report the incident immediately, and the resident's complaints of pain were not addressed until several days later. The resident expressed that she was in pain following the accident and had to remain in bed for eight weeks due to the injury. The facility staff, including the Physical Therapist and Regional Director of Operations, confirmed that the DOT failed to report the incident promptly, which delayed the resident's treatment. The facility's staff, including the Administrator and Nurse Practitioner, acknowledged the delay in reporting the incident and the subsequent injury. The Administrator noted that the DOT was suspended and later terminated for neglecting to use the footrest and failing to report the incident. The Nurse Practitioner confirmed that the resident was sent for an x-ray after complaints of pain, which revealed the fracture. The incident highlighted a lapse in communication and adherence to safety protocols within the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations of unclean and unsanitary conditions in 12 resident rooms and common areas. The surveyors observed long streaks of dark brownish stains on the handrails in the hallways, and multiple resident rooms had dust and dirt on air conditioning units, air filters, and vents. Additionally, the bathrooms in these rooms had dirt particles, built-up dirt stains, and dark stains in the shower areas, with some rooms having stained shower curtains and rusted handrails. Interviews with housekeeping staff revealed that the cleaning procedures were not being followed consistently. A housekeeper, who had been at the facility for two weeks, stated that she was trained by shadowing another housekeeper and was unsure who was responsible for cleaning the handrails. She mentioned that deep cleaning was done for 2 to 3 rooms a day, but there was no clear schedule for cleaning air filters or handrails. The Housekeeping Supervisor confirmed that the rooms, handrails, and showers were supposed to be cleaned daily and acknowledged the lack of a schedule for cleaning shower curtains. The facility's Administrator admitted that the cleanliness and physical appearance of the facility needed improvement and that key leadership was not consistently conducting Angel rounds to ensure resident well-being. The facility's policy on maintaining a safe and homelike environment emphasized the importance of cleaning and sanitization, but the observed deficiencies indicated a failure to adhere to these standards, potentially leading to contamination.
Infection Control Deficiencies in Hand Hygiene and Cross-Contamination
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in several deficiencies related to hand hygiene and cross-contamination. One incident involved a CNA who did not change gloves or perform hand hygiene after providing incontinent care to a resident, potentially transferring contaminants from soiled to clean areas. The CNA acknowledged the oversight and recognized the risk of cross-contamination and infection. Another deficiency was observed when an RN brought a container of test strips into a resident's room while checking blood sugar levels. The RN admitted that the container should have remained on the cart, as it was used for multiple residents, and bringing it into the room could lead to cross-contamination. The RN understood that the best practice was to avoid bringing shared items into individual resident rooms. Additionally, a medication aide failed to perform hand hygiene before and after administering medications to multiple residents. This lapse in protocol was acknowledged by the aide, who noted the importance of hand hygiene in preventing contamination. Furthermore, during wound care for a resident with a pressure ulcer, an RN and a CNA did not sanitize their hands between glove changes, despite handling soiled items. Both staff members recognized the importance of hand hygiene in preventing the spread of germs and cross-contamination.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to maintain the dignity of Resident #53, a cognitively intact male with a neuromuscular dysfunction of the bladder, by not providing a privacy bag for his catheter bag. Despite having a physician's order for a privacy bag to be used every shift, observations revealed that the catheter bag was visible without a privacy cover, which was confirmed by both the resident and staff members. The resident was unaware of the exposure, and staff interviews indicated that the lack of a privacy bag could lead to embarrassment or discomfort for the resident. Interviews with the LVN, CNA, DON, ADON, and the Administrator confirmed the expectation that catheter bags should be covered with privacy bags to maintain resident dignity. The facility's policy on catheter care also stipulated the use of privacy bags to promote hygiene, comfort, and dignity. The failure to adhere to these policies and procedures resulted in a deficiency in treating the resident with respect and dignity, as required by the facility's standards and resident rights policies.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the storage of respiratory equipment. Resident #20, a female with chronic obstructive pulmonary disease (COPD) and shortness of breath, was observed with her nebulizer mask improperly stored on top of the nebulizer machine without being bagged. This part of the mask, which touches the face during use, was in contact with the machine's surface. The resident reported that the nurse would sometimes leave the mask on the table after treatment, and she had never seen a bag for her nebulizer mask. Similarly, Resident #45, also diagnosed with COPD and shortness of breath, was found with her nasal cannula hanging on the oxygen concentrator without being bagged. The nasal cannula was not stored in a plastic bag, which is necessary to prevent contamination. An LVN confirmed the improper storage of both the nebulizer mask and the nasal cannula, acknowledging that they should not be exposed or touching surfaces to avoid cross-contamination and infection. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's policy requires respiratory equipment to be bagged when not in use to prevent infection. The DON and ADON both stated that the staff is responsible for ensuring proper storage of respiratory equipment, and the expectation is for these items to be bagged when not in use. The facility's policy on respiratory treatment and care emphasizes the importance of following infection control practices, including the proper handling and storage of equipment.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide appropriate assistive devices to a resident who needed them to maintain or improve their ability to eat or drink independently. The resident, a cognitively intact female with multiple diagnoses including lack of coordination, was served hot coffee in a handle-free tumbler, which she could not grasp due to contractures in her hands. This resulted in the coffee spilling and scalding her right upper chest. The resident's care plan indicated the need for a cup with handles, but this was not provided. Instead, the resident was using a personal handle-free tumbler, which was not safe for her condition. The resident had previously insisted on using her personal cup, but there was no documentation of the facility providing or suggesting safer alternatives. The incident occurred when a CNA used the resident's personal tumbler to serve coffee, leading to the spill and subsequent injury. Interviews and observations revealed that the staff was unaware of any special equipment available for the resident to assist with eating or drinking. The resident's care plan and progress notes did not reflect recommendations for adaptive eating equipment, and the facility's policy on assistance with meals was not followed. The incident highlighted a lack of appropriate adaptive equipment and staff awareness, which contributed to the resident's injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 982 citations issued within 25 miles in the last 12 months — including the 41 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Coppell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Ridge Nursing & Rehabilitation Center | 2.5 mi | — | 13 | 0 |
| Heritage Gardens Rehabilitation And Healthcare | 2.6 mi | — | 5 | 0 |
| Carrollton Health And Rehabilitation Center | 3.3 mi | — | 10 | 0 |
| The Madison On Marsh | 5.5 mi | — | 2 | 0 |
| Brookhaven Nursing And Rehabilitation Center | 5.8 mi | — | 3 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sandy Lake Rehabilitation And Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.