Balch Springs Nursing Home

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain documentation showing that Resident #13’s representative had been delegated the authority to exercise the resident’s rights, and it did not verify that any court-appointed representative had authority for the specific decision-making at issue. Resident #13 was admitted with diagnoses including cerebral infarction, bipolar disorder, schizoaffective disorder, altered mental status, legal blindness, malignant neoplasm of the larynx, dementia, and cognitive communication deficit. The record showed severe cognitive impairment, with a BIMS score of 02, and the care plan stated that he had impaired cognition, was at risk for further decline, and needed supervision and assistance with all decision making. The resident’s face sheet did not list any family members or resident representatives. A progress note stated that he was a new admit, was blind, required full care, and had no family member listed on the admission sheet. During observation, Resident #13 was lying in bed and did not respond to the surveyor’s questions. CNA staff stated they had never seen him have visitors and were not aware of any family members or resident representative. The social worker stated that the facility had not pursued guardianship, that care plan meetings were held in the resident’s room, and that the resident did not participate because he could not make decisions for himself. The DON stated that a resident who cannot communicate should have a guardian or representative to inform staff of the resident’s wishes and for proper care, and that if there is no family or representative, the facility must reach out to the physician to make sure the resident has a representative. The NP stated that Resident #13 could communicate immediate needs but not make decisions about care plans or activities, had no known family members or guardians, and that there were no orders designating anyone as guardian or representative. The facility’s Resident Rights policy stated that the resident has the right to have a legal representative.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility through means other than the postal service, for 6 confidential residents reviewed for communication privacy rights. During a confidential group interview, 6 of 9 members stated they never received mail, and 3 of 9 residents stated mail was not distributed at the facility on Saturdays because the Activity Director did not work on Saturdays. During interviews, the Activity Director stated she was responsible for delivering mail and that she passed residents' mail Monday through Friday, but was not present on weekends and was not sure whether any staff were assigned to pass mail on Saturdays. She also stated that when she arrived on Monday, mail was in her box to pass out. The Administrator stated her expectation was for mail to be passed on Saturday by weekend staff, and that there was not one specific person assigned to pass mail on the weekend, only nursing staff in general. Record review of the facility policy titled Resident Right to Privacy in Communication stated that mail or other materials should be delivered to the resident within 24 hours of delivery by the postal service, including a post office box, and outgoing mail should be delivered to the post office within 24 hours except when there is no regularly scheduled postal delivery and pick-up service.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to send a copy of Resident #8’s discharge notice to the representative of the Office of the State Long-Term Care Ombudsman before the resident was discharged. Resident #8’s nursing home discharge MDS assessment dated 04/13/2026 identified him as a [AGE]-year-old male admitted to the facility on [DATE], with an active diagnosis of ischemic cardiomyopathy and a blank BIMS score. During interview, the Ombudsman stated she had never received a discharge notification from the facility and said the facility was required to submit discharge notification every time it did an involuntary discharge, transfer, or presented discharge paperwork to a resident related to discharge. The Social Worker stated she had no evidence of a report to the state Ombudsman for Resident #8’s discharge and was not aware she was supposed to send discharge notification monthly. The Administrator stated she was unaware of the rule to notify the state Ombudsman of any resident discharges. Record review of the facility’s Transfer and discharge policy stated that a copy of the notice shall be provided to the representative of the Office of the State Long-Term Care Ombudsman and that the Social Services Director, or designee, shall provide notice of transfer via monthly list.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate assessments with the PASRR program for one resident who had schizoaffective disorder, bipolar disorder, and anxiety disorder. Record review showed the resident’s quarterly MDS assessment reflected severe cognitive impairment with a BIMS score of 13, and the care plan documented behavior problems related to delusions, hallucinations, and false allegations toward others. The resident’s PASRR Level 1 screening dated 06/18/25 indicated she did not have a mental illness, even though the record also reflected mental illness diagnoses of schizoaffective disorder, bipolar disorder, and anxiety. During interview, the DON stated that if a resident received a new diagnosis, a new PASRR evaluation should be completed, and the Regional MDS Nurse stated the same. The Regional MDS Nurse reviewed the chart and stated the resident did not have a dementia diagnosis and had diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder, but the PASRR Level 1 was negative and did not reflect those mental health diagnoses. She stated she was unable to explain why a new PASRR Level 1 had not been completed when the new diagnoses were found. The ADM stated it was her expectation that the MDS Nurse ensure residents had a PASRR completed prior to admission and that if any resident received a new MI or developmental disability diagnosis while in the facility, the MDS Nurse was responsible for creating a PL1 to submit to the local authorities. Facility policy stated that if a resident had a qualifying MI or ID diagnosis and the nursing facility felt the resident should be positive, the referring entity should be contacted to correct the PL1 or complete the 1012, and that the facility must not accept admission from a hospital without a PL1.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. Resident #18 was a female admitted to the facility with diagnoses including end-stage renal failure and diabetes. Her quarterly MDS reflected a BIMS score of 13 and moderately impaired cognitive skills for daily decision making. Her care plan identified an ADL self-care performance deficit and required extensive assistance of two staff for toileting. During an observation of incontinence care, CNA A unfastened the resident’s brief, cleaned the vaginal area, and used the same soiled gloves to pick up trash bags, pulling one off and placing it on the bed. CNA A then placed the roll of trash bags in her pocket. After turning the resident to her left side, CNA A cleaned the buttocks and changed gloves but did not perform hand hygiene before placing a clean brief under the resident. In interview, CNA A stated she was supposed to perform hand hygiene when changing gloves and said she was trained to use hand sanitizer but forgot. She also stated she was not supposed to place clean trash bags in her pocket with soiled gloves and that failing to change soiled gloves and perform hand hygiene could cause infection. The DON stated staff were supposed to perform hand hygiene between glove changes and use clean gloves to place items in their pockets.

Penalty

Inspection fine: $43,095

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer prevention and treatment services, consistent with professional standards, for a severely cognitively impaired, bedbound resident who was always incontinent and fully dependent on staff for mobility and transfers. On admission from the hospital, the resident had no heel wounds but did have a history of skin issues on the buttocks and peri-area, and the hospital’s wound care documentation included a prevention plan directing that the heels be offloaded using heel protector boots or pillows. The resident’s care plan identified her as at risk for pressure ulcers, with goals to prevent breakdown and interventions such as frequent incontinence care, bathing per schedule, weekly skin checks, and nutritional support, but it did not include specific interventions for heel offloading or repositioning every two hours. The record shows that the facility did not consistently assess and monitor the resident’s skin condition as ordered. A Braden Scale assessment was completed once, rating the resident as low risk, and no further Braden assessments were found. Physician orders dated 12/31/2025 required head-to-toe skin assessments and documentation of any changes in skin integrity on specified days, with physician notification of changes, yet there was no evidence these assessments were performed on multiple ordered dates. The EHR contained no documented Skilled Observation Notes used as skin assessments for a prolonged period, and later Skilled Observation Notes uniformly described the skin as intact with no notable changes, despite the subsequent development of heel blisters and pressure injuries. The DON later acknowledged that skin assessments were not documented in the EHR and that only changes in skin integrity were recorded in progress notes. When blisters on both heels were identified on 02/09/2026, the nurse practitioner ordered daily skin prep to the bilateral heel blisters and offloading of both heels with heel protectors while in bed. However, the MAR/TAR showed multiple shifts where heel offloading was not documented as provided, and there were several days when the ordered skin prep was not documented as applied. CNAs reported that heel protectors were sometimes removed by nurses, that the resident sometimes refused them, and that bandages were often not changed over weekends. The wound care physician, who began seeing the resident after the heel wounds developed, noted that the resident was sometimes not wearing heel protectors and attributed the wound development to immobility and general decline. By 03/10/2026, the resident’s right heel remained an unstageable deep tissue injury and the left heel had progressed to a Stage 4 pressure wound. The facility’s own skin integrity policy required repositioning at-risk residents at least every two hours and use of pillows or wedges to keep bony prominences from direct contact, but the DON later confirmed that the resident’s care plan lacked interventions for heel offloading or repositioning, and there were no orders for an air pressure mattress.

Removal Plan

• DON/ADON conducted an audit of all current residents to identify those at risk for pressure injuries (limited mobility, dependence for repositioning, malnutrition, existing wounds, recent decline); screened all residents and identified at-risk residents.
• Completed updated skin assessments on all residents and filed them in the medical record under the document tab.
• Verified pressure-relieving devices for identified at-risk residents (physician order as required, care planned, and device in place).
• Reviewed treatment orders for all at-risk residents to ensure treatment orders exist for all identified skin issues; notify MD to obtain orders when missing.
• Reviewed nutritional status for all at-risk residents to ensure nutrition assessment completed; obtain MD orders as needed; update care plan; RD review.
• Reviewed and updated care plans for all at-risk residents to address skin concerns including wounds, treatment, pressure-relieving devices, repositioning, and nutrition.
• Revised and reinforced the process for timely risk identification on admission and with condition change using the 24-hour report; DON/MDS to review every admission and condition change to ensure conditions are identified and addressed.
• Implemented weekly skin assessments completed by charge nurse with ADON auditing after completion.
• Implemented physician notification process: charge nurse to notify physician of identified skin issues; DON to audit physician notification through progress notes.
• Implemented wound consultant follow-up process: ADON to round with wound physician; ADON to implement orders and new treatments.
• Implemented care plan revision process: charge nurse/ADON/MDS to revise care plan following required change; DON to audit care plan changes.
• Implemented heel offloading process for applicable residents: charge nurse/CNAs responsible for offloading heels while residents are in bed; ADON/DON to validate using a monitoring sheet; DON to develop and maintain a list of residents requiring heel offloading.
• Re-educated licensed nurses and CNAs with post-test on pressure injury risk recognition, repositioning and offloading techniques, immediate reporting of skin changes, and documentation of skin checks on skin observation sheets; administrator to track attendance and post-tests.
• Implemented ongoing monitoring and audits by DON/ADON of residents with current pressure injuries, residents at risk for skin breakdown, repositioning documentation, weekly skin assessments, wound treatment compliance, and care plan updates.
• Correct negative audit findings immediately, including staff counseling and re-education, resident reassessment, physician notification, and care plan revision as indicated.
• Report audit findings and trends to the QAPI Committee for ongoing review and additional action if needed.
• Notified the Medical Director of the IJ and discussed and obtained approval of the plan of removal.

Penalty

Inspection fine: $43,095

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes that reflected a resident’s identified needs for pressure injury prevention. The resident was an older female with multiple complex medical conditions, including malnutrition, COPD/asthma, toxic encephalopathy, alcohol dependence, muscle wasting and atrophy of the lower leg, cognitive communication deficit, and muscle weakness. A quarterly MDS showed severe cognitive impairment with a BIMS score of 6, total dependence for transfers and mobility, and complete bowel and bladder incontinence. The resident either refused or was unable to perform basic mobility tasks such as sit-to-lying, lying-to-sitting, sit-to-stand, transfers, and walking, placing her at high risk for pressure injuries. The resident’s care plan, initiated for pressure ulcer risk, identified a focus of potential for development of a pressure ulcer with a goal that the resident would be free of preventable breakdown. Interventions listed included frequent checks for wetness and soiling, incontinence care every two hours as needed, scheduled bathing, and weekly skin checks with reporting of new skin conditions to the physician. However, the care plan did not include interventions for off-loading the heels or repositioning every two hours, despite the resident’s immobility and incontinence. The Braden Scale completed at admission rated the resident as low risk with a score of 16, and the facility’s documentation showed no skilled observation notes for skin assessments from early January through late February, and subsequent notes described the skin as intact with no notable changes. Hospital documentation in the facility’s EHR from before admission showed a prevention plan that specifically ordered heel off-loading using heel protector boots or pillows lengthwise. Later, a wound care physician’s evaluation documented that the resident developed unstageable deep tissue injuries (DTIs) on both heels, and a subsequent evaluation showed an unstageable DTI on the right heel and a Stage 4 pressure wound on the left heel. Interviews indicated that the family representative had not observed heel boots or pillows under the resident’s legs until after bandages were applied, and the NP reported that the resident had been admitted without pressure ulcers or DTIs, later developed heel blisters, and that orders for off-loading and heel boots were written. The DON and ADON acknowledged that repositioning was not reflected on the TAR/MAR, that heel riser boots had not yet been received, and that the care plan lacked interventions for off-loading heels and repositioning. These documented omissions and inconsistencies in care planning and implementation led to the identified deficiency under F656 for failure to develop and implement a comprehensive person-centered care plan.

Removal Plan

• DON/ADON conducted an audit of all current residents to determine which residents are at risk for pressure injuries (limited mobility, dependence on staff for repositioning, malnutrition, existing wounds, or recent decline).
• DON/ADON conducted an audit of residents identified as high-risk for skin breakdown (Braden scale score below 10) and reviewed residents with current wounds and significant change of condition to validate that comprehensive care plans addressed all issues with appropriate interventions and were updated as needed.
• For any resident identified with missing, incomplete, or outdated care plan interventions, the care plan was reviewed and revised immediately by the MDS Coordinator and DON.
• MDS nurse completed care plan updates for identified residents.
• DON/ADON re-educated licensed nurses, MDS staff, and interdisciplinary team members on requirements for comprehensive person-centered care planning, timely care plan revision after new wounds/condition changes, measurable objectives and individualized interventions, and communication of updated interventions to direct care staff via Kardex/POC system and documentation of care plan review/implementation.
• Implemented expectation that care plans are revised as soon as an issue is identified by the ADON responsible for wound care, with DON validating care plan revisions during morning meeting.
• Required that staff who did not attend the education will not work until education is completed; Administrator to track attendance and posttest completion.
• Established ongoing monitoring/audits by DON/ADON/MDS Coordinator for residents with new wounds, current pressure injuries, significant changes in condition, and identified skin risk factors to verify care plans are revised timely and interventions are individualized and implemented.
• Set audit schedule through QAPI as indicated.
• For any negative audit findings, correct immediately through care plan revision, staff re-education, and follow-up review.
• Bring audit results to the QAPI Committee for review, trend analysis, and additional corrective action as needed.
• Notified the Medical Director of the Immediate Jeopardy and discussed/obtained approval of the plan of removal.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specific deficiencies included the failure to accurately label and date food items with their received or expiration dates, which is crucial for maintaining food safety. Additionally, dented cans were not stored in a separate area as required, and opened food items were not effectively sealed or resealed. These lapses in food storage and handling could potentially lead to food-borne illnesses and cross-contamination, posing a risk to residents. During the survey, it was observed that a box of cream of wheat was left open and exposed to air, and several bags of hot dog buns lacked use-by or expiration dates. A dented can of cream of chicken was also found improperly stored. Interviews with the dietary manager and another staff member confirmed that these practices were not in line with the facility's food storage policy, which mandates proper sealing, labeling, and storage of food items. The facility's policy and the U.S. FDA Food Code emphasize the importance of these practices to prevent contamination and ensure food safety.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident #10, an elderly female with severe cognitive impairment and a history of pressure ulcers, was not repositioned every two hours as per physician orders. Observations over several days showed that she remained in the same position without the use of pillows or wedges for repositioning, despite her care plan indicating the need for frequent repositioning to prevent skin breakdown. A new wound was noted on her coccyx, indicating a lapse in care. Similarly, Resident #32, who also had severe cognitive impairment and a stage 4 pressure ulcer, was not repositioned every two hours as required by her care plan. Observations revealed that she was consistently found lying flat on her back, with wedges not properly utilized for repositioning. Despite recommendations to reposition her every one to two hours, the facility failed to adhere to these guidelines, potentially contributing to the chronic nature of her wound. Interviews with staff, including CNAs and RNs, highlighted inconsistencies in the repositioning practices and a lack of clarity on the frequency of repositioning for these residents. The facility's policy on skin management was not effectively implemented, as evidenced by the lack of a specific repositioning policy and the failure to prevent new skin alterations. The DON and ADON acknowledged the need for regular repositioning but did not ensure compliance with the care plans, leading to the observed deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that drug regimen irregularities reported by the Pharmacist Consultant were acted upon for two residents. Specifically, the recommendations for a gradual dose reduction (GDR) of certain medications for these residents were not addressed by the attending physician. For Resident #19, the Pharmacist Consultant recommended a GDR for Citalopram and Quetiapine, but there was no documented physician rationale for continuing these medications without a dose reduction. Similarly, for Resident #9, recommendations for a GDR of Risperidone and Divalproex were made, but again, there was no documented physician rationale for not implementing the dose reductions. Resident #19, a male with diagnoses including Alzheimer's Disease, schizoaffective disorder, and dysphagia, was noted to have intact cognition with a BIMS score of 14. Despite receiving antipsychotic and antidepressant medications, there were no behavioral symptoms exhibited. The care plan for Resident #19 included monitoring for side effects and providing positive reinforcement, but the lack of physician response to the pharmacist's recommendations left the medication regimen unchanged without documented justification. Resident #9, also a male with schizophrenia and major depressive disorder, had a BIMS score of 15, indicating intact cognition. He was receiving antipsychotic medications without exhibiting behavioral symptoms. The care plan aimed to maintain the resident's functional abilities and reduce psychoactive medication use, yet the pharmacist's recommendations for dose reductions were not addressed by the physician. Interviews with facility staff and the physician revealed a lack of clarity and documentation regarding the process for handling pharmacist recommendations, contributing to the oversight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically concerning the 200 hall medication cart. During an observation and interview, it was found that two insulin pens, an Aspart insulin syringe and a Tresiba insulin pen, lacked open dates, although the seals were missing, indicating they had been opened. Additionally, two other insulin pens, a Lyumjev and an Admelog, were found to have been opened 46 days prior, exceeding the recommended 28-day usage period. RN D incorrectly stated that the long-acting insulins were good until the manufacturer's expiration date, and there was no risk to residents, despite the lack of open dates and extended usage. The Director of Nursing (DON) confirmed that all insulins, including long-acting ones, require an open date and should be discarded after 28 days to ensure effectiveness. The Assistant Director of Nursing (ADON) also stated that insulin must have an open date and be discarded after 28 days, as undated insulin cannot be used. The facility's policy mandates that all medications be stored, dated, and labeled according to the manufacturer's recommendations, and medication carts are to be routinely inspected for outdated or improperly labeled medications. The failure to adhere to these guidelines could potentially compromise the therapeutic effects of the medications administered to residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure a resident maintained acceptable nutritional status by not completing a required annual comprehensive nutritional assessment or a nutrition assessment after an identified weight loss. The last comprehensive nutritional assessment for the resident was completed over a year prior, and despite documentation of unintended weight loss by the dietician, no follow-up assessment was performed as required by facility policy. Additionally, the facility did not implement dietary recommendations made by the dietician, which included initiating a magic cup supplement and obtaining weekly weights for four weeks. There were no physician orders entered for these interventions after the recommendations were made, and weight records showed that weekly weights were not consistently obtained. The care plan indicated that supplements should be provided as ordered, but this was not carried out. Interviews with facility staff revealed a lack of clarity and follow-through regarding responsibility for implementing dietary recommendations and ensuring assessments were completed. The dietician reported sending recommendations to the DON, ADON, and dietary manager, but these were not acted upon. The DON and ADON acknowledged their roles in entering orders and monitoring compliance but did not ensure the recommended interventions were implemented for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, specifically in the administration and documentation of insulin. The resident, a cognitively intact female with type 2 diabetes and high blood pressure, did not receive her prescribed insulin on three occasions. The medication administration record (MAR) for August 2024 showed no documentation of insulin administration or blood sugar checks on these dates. The resident reported that she did not receive her insulin during the night shifts covered by a specific LVN, although she was unaware of any adverse effects from the missed doses. The Director of Nursing (DON) was unaware of the documentation lapses until informed. Upon inquiry, the LVN claimed to have administered the insulin but failed to document it. This lack of documentation posed a risk of another nurse administering an extra dose, potentially leading to medical complications. The facility's failure to ensure proper documentation and administration of medication could compromise the therapeutic dosages ordered by the physician.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by their policy. On 05/24/24, Medication Cart #1 was observed unlocked and unattended with the keys left on top of the cart. This cart was positioned facing the entrance of a resident's room, and residents were present in the room at the time. Charge Nurse A, who was responsible for the cart, was not present as he had left to assist with food trays. Upon returning approximately five minutes later, Charge Nurse A acknowledged the oversight and expressed regret for leaving the cart unsecured. Interviews conducted with the facility's Administrator and Director of Nursing B confirmed that it is a requirement for medication carts to be locked at all times when unattended. Both acknowledged the risk associated with leaving the cart unlocked, as it could allow unauthorized access to medications. A review of the facility's policy on medication storage, dated 1/20/21, reiterated that all drugs and biologicals must be stored in locked compartments and only authorized personnel should have access to the keys. The policy also specifies that during medication passes, medications must be either under direct observation or locked in the storage area or cart.