Health inspection·February 13, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #58) reviewed for quality of care. Residents Affected - Some The facility failed to ensure Resident #58 did not have a wound bandage on her right elbow, dated 02/01/25, when observed for wound care on 02/11/2025. This failure could place residents at risk of prolonged wound healing and infection. The findings include: Record review of Resident #58's Face Sheet, dated 02/11/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #58 had diagnoses which included Rheumatoid arthritis (chronic inflammation of joints and other parts of the body) and age-related physical debility. Record review of Resident #58's Quarterly MDS Assessment, dated 11/12/2024, reflected Resident #58 was cognitively intact with a BIMS score of 14. Section M indicated Resident #58 had skin tears and was treated with the application of non-surgical dressings. Record review of Resident #58's Physician Orders did not reflect an order for a wound dressing on the resident's right elbow. Record review of Resident #58's Comprehensive Care Plan, dated 02/01/2025, reflected resident was at high risk for skin related injury due to chronic conditions, impaired mobility, incontinence, and dependence on staff for ADL's. One intervention was nurse or wound care team will provide wound care per MD's orders. Review of Resident #58's wound details, dated 02/13/2025, reflected the right elbow had Partial flap loss: flap cannot be repositioned to cover the wound and the wound measured 2.1 x 0.8 cm. The wound details did not reflect signs of infection. Observation and interview on 02/11/25 AT 11:08 AM revealed a dressing on Resident #58's right elbow, dated 02/01/25. The Wound Care Nurse stated he did not recognize the nurse's initials on the dressing. He stated he had just returned to work after taking time off and agency nurses provided wound care during his absence. The Wound Care Nurse removed the dressing on Resident #58's right elbow. An Page 1 of 11 675757 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assessment revealed dried blood and a scant amount of serosanguinous (mix of clear serous fluid and blood) drainage on the dressing. The Wound Care Nurse covered the wound with clean gauze, washed his hands in the resident's restroom, and went into the hall to look at the Physician's Orders on his laptop. The Wound Care Nurse stated there was no order for a dressing on the right elbow. He stated the nurse who assessed and provided the wound care should have added an order for a dressing so other nurses would know to change the dressing. The Wound Care Nurse called the resident's doctor, reported the skin tear, and received an order for wound care. The Wound Care Nurse stated there was a standing order for residents who received a skin tear to be changed three times a week, on Tuesday, Thursday, and Saturday. During an interview on 02/12/2025 at 10:40 AM, the ADON stated there was a standing order for treatment of skin tears. She stated if an order was not in Resident #58's chart, the nurses might not be aware there was a dressing on the elbow. She stated it could cause infection if the dressing stayed on the wound longer than it should. During an interview on 02/12/2025 at 12:20 PM, the DON stated the facility used agency nurses to provide wound care for a few days while the wound care nurse was out. She stated there were standing orders for a skin tear and any nurse could put an order in the resident's chart. She stated if a wound was not monitored, and the dressing changed as ordered, it could get infected. Record review of the facility's policy Wound Care: Dressing Change , revised January 2025, reflected provide step-by-step guidelines for the care of wounds to promote healing .apply treatments as indicated by provider's order. 675757 Page 2 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 4 residents (Resident #10 and #80) reviewed for Respiratory Care. Residents Affected - Few 1. The facility failed to ensure Resident #10's CPAP hose, for the CPAP machine was placed in a sanitary area and not on the floor. 2. The facility failed to ensure Resident #80's nasal cannula, for the oxygen concentrator was placed in a sanitary container when not in use. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: 1. Record review of Resident #10's face sheet, dated 10/23/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #10's relevant diagnoses included sleep apnea (sleep disorder), and chronic atrial fibrillation (irregular heartbeat). Record review of Resident #10's Quarterly Minimum Data Set, dated [DATE], reflected, he had a Brief Interview for Mental Status score of 9, severe cognitive impairment) and for active diagnosis it reflected sleep apnea. Record review of Resident #10's Comprehensive care plan, dated 12/30/24, reflected the resident required oxygen therapy and used a sleep apnea machine for sleep apnea obstruction. Record review of Resident #10's Physician Order, dated 02/11/25, reflected CPAP on at HS (SETTINGS 9/13) At Bedtime 21:00 In an interview and observation on 02/11/25 at 11:29 AM, LVN observed Resident #10's CPAP Hose was sitting on the floor, disconnected from the mask, which was bagged. LVN S stated the hose should not have been on the floor because it could be contaminated, and it was an infection control concern. 2. Record review of Resident #80's face sheet, dated 02/11/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #80's relevant diagnoses included sleep apnea (sleep disorder), and Intracardiac thrombosis (blood clots). Record review of Resident #80's Quarterly Minimum Data Set (MDS), dated [DATE], reflected he had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognitive response. Resident #80 had active treatments which included continuous oxygen therapy. 675757 Page 3 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #80's Comprehensive care plan, dated 01/30/25, reflected the resident required oxygen therapy and reflected Administer oxygen at 0-4L (rate) via NC (device). Observe oxygen precautions. Record review of Resident #10's Physician Order, dated (02/11/25), reflected respiratory: O2 at 0-2l/min at start -per NC - titrate up 1l/min to maintain O2 sats >92% Special Instructions: Continuous O2 at 0-2L/min to maintain O2 SATS >92% In an interview and observation on 02/11/25 at 10:57 AM, LVN T observed Resident #80's nasal canula hanging on her headboard and unbagged and she was not in the room. LVN T stated the resident's nasal canula should have been bagged to avoid it from getting contaminated. The tubing was observed balled up on the floor and the tubing should not touch the ground because it could be contaminated, and it was an infection control concern. In an interview on 02/13/25 at 9:00 AM, the DON was advised of Resident #10's hose for his CPAP machine being on the floor and Resident #80's nasal canula not being bagged while not in use. She stated both concerns could cause respiratory issues and it was an infection control concern. She stated she completed in-services with the nursing staff on oxygen and tubing, which covered storing the resident's nasal canula and the CPAP machine when not in use from 12/06/24 to 12/13/24. In an interview on 02/13/25 at 09:30 AM, the Executive Director was advised of the concerns observed with Resident #10's hose for his CPAP machine being on the floor and Resident #80's nasal canula not being bagged while not in use. She stated that both concerns are infection control concerns. She advised she would follow up with the DON. Record review of the facility's policy, Respiratory Therapy. (11/2011) revealed The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .8. Keep the oxygen cannulas and tubing used PRN in a plastic bag when not in use. 675757 Page 4 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 12 residents (Resident #40) reviewed for medication storage. The facility failed to ensure Resident #40 didn't have a box of Mucinex (medication used to treat the symptoms of cough and congestion) tablets left unattended and unsecured on the bedside table on 02/11/2025. This failure could place residents at risk for misappropriation of property, risk for accidents, hazards, and not receiving therapeutic effects of the medication. The findings include: Record review of Resident #40's Face Sheet, dated 02/11/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #40 had diagnoses which included Covid-19 (respiratory illness caused by a virus) and acute respiratory failure (respiratory condition that makes it difficult to breathe). Record review of Resident #40's Quarterly MDS (tool used to assess health and functional capabilities status of resident) Assessment, dated 01/05/2025, reflected Resident #40 had severe cognitive impairment with a BIMS score of 07. Section I did not reflect current treatment for a pulmonary (lung related) condition. Record review of Resident #40's Physician Orders, dated 03/13/2022, reflected Mucinex D 60-600 mg tablet extended release 12 hr 600mg, oral, Twice A Day - PRN. Record review of Resident #40's Comprehensive Care Plan, dated 01/05/2025, reflected the resident was at risk for progression/onset of opportunistic infection related to Covid-19 virus positive status (per CDC recommendation) - Resolved. One intervention was to administer medications and treatments as ordered. Record review of Resident #40's Continuity of Care, dated 02/14/2025, reflected the last dose of Mucinex D was administered by facility staff on 09/19/2023 at 01:58 PM. Observation and interview on 02/11/2025 AT 10:46 AM revealed an open box of Mucinex on Resident #40's bedside table. The box of Mucinex was in a plastic organizer that held the resident's personal items. Resident #40 stated her family member brought the box of Mucinex to her a long time ago, but she had not taken any of the medication. During an interview on 02/11/2025 at 10:53 AM, the ADON stated the medication should not have been in Resident #40's room. She stated an assessment and physician's order was required for a resident to self-administer medication and Resident #40 did not have an assessment included in her chart to self-administer medication. The ADON stated the resident could have taken the medication and staff 675757 Page 5 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few also gave the medication to the resident. The ADON stated we do not want her to overmedicate. The ADON removed the medication from Resident #40's room. During an interview on 02/11/2025 at 11:01 AM, LVN C stated she had not seen the Mucinex in Resident #40's room. LVN C stated the Mucinex should not have been in Resident #40's room. She stated the resident might take more than the directions said and staff would not know. LVN C stated residents could only have medication in their room if the doctor authorized it. During an interview on 02/12/2025 at 12:20 PM, the DON stated sometimes family brought things to residents and staff did not know about. The DON stated the administrator contacted Resident #40's family and asked them not to bring medication to the resident's room. The DON stated another resident could go in Resident #40's room and take the medication. The DON stated a resident was required to pass an assessment and have a physician's order to self-administer medication. Record review of the facility's policy Self-Administration of Medications , revised February 2021, reflected Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. 675757 Page 6 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the kitchen staff wore the appropriate beard and hair covering while food was being prepared in the main kitchen. 2. The facility failed to ensure the food stored in the refrigerator was properly sealed from air-borne contaminants. 3. The facility failed to ensure the ice machine in the basement area was cleaned and the ice scoop holder was not exposed to air-borne contaminants. 4. The facility failed to cover a large trash can stored in the kitchen area. 5. The facility failed to ensure the food storage bins in the dry storage area were cleaned. 6. The facility failed to discard expired food in the refrigerator. 7. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 02/11/25 from 9:10 AM to 9:17 AM in the facility's main kitchen revealed: The ice machine door, located in the basement outside of the kitchen, had white and brown dirt stains inside the door and a white plastic piece located above the ice had black dirt and rust on it. The ice scoop was sitting in a holder, but it was exposed to airborne contaminants because it was not covered. 675757 Page 7 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0812 One large trash can, which contained food and trash, in the kitchen area, was uncovered. Level of Harm - Minimal harm or potential for actual harm One tubing of whip cream, stored in the refrigerator, had a use by date of 02/05/25 and was not discarded. Residents Affected - Some Dish water T was observed walking around the kitchen area, and he was observed to have a beard that was at least a ¼ inch in length, but no beard covering was worn. Cook S and [NAME] B were wearing baseball caps but had large ponytails, at least 2 inches in length protruding from the baseball caps. Four large storage bins containing rice, flour, sugar, and breadcrumbs, were in dirt-stained containers. The containers had brownish and black stains on the outside and inside of the containers. One large box of bacon, located in the freezer, was not sealed, and exposed to airborne contaminants. One large tea dispenser, located in the kitchen area, did not have a lid placed on the top dispenser to avoid air-borne contaminants. In an interview on 02/12/25 at 12:46 PM, the DM was advised of Dishwasher T being observed with a beard, approximately more than a ¼ inch in length, and no beard covering was worn. She was also advised [NAME] S and [NAME] B were wearing baseball caps but had large ponytails protruding from the baseball caps. The DM was advised of their entire hair needing to be covered to avoid hair from falling into the resident's food. She stated this was her fault because she was not aware of this. She advised she would be correcting this concern. She was shown pictures of the concerns in the main kitchen, and she stated the cooks and dishwashers were responsible for ensuring the kitchen equipment, be cleaned at least once a week. She stated the ice machine was cleaned by maintenance monthly and she would meet with them to clean it. She stated she would get with the ED to discuss getting a suitable container to hold the ice scoop to avoid it being in the open and exposed to airborne contaminants. In an interview on 02/13/25 at 09:30 AM, the Executive Director was advised and shown pictures of the concerns observed in the facility's main kitchen area. She advised she had not met with her Dietary Manager yet to address the concerns. She stated the concerns not being addressed could result in food contamination and residents could get sick. She stated she would follow up with the DM. Record review of the facility's policy on Food Receiving and Storage (November 2022), revealed Foods shall be received and stored in a manner that complies with safe food handling practices .1. All foods stored in the refrigerator or freezer are covered, labeled and dated ('use by' date) .7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded. Record review of the facility's policy on Food Safety and Sanitation (2023), revealed, All local, state, and federal standards and regulations will be followed to assure a safe and sanitary food and nutrition services department .c. Employees are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes, and closed toe shoes. o 675757 Page 8 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0812 Hair restraints are required and should cover all hair on the head. Level of Harm - Minimal harm or potential for actual harm o Beard nets are required when facial hair is visible . Residents Affected - Some 6. Employees will follow proper cleaning and sanitizing instructions for all kitchen equipment. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18 .Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Record review of Title 21--Food and Drugs Chapter I--Food and Drug Administration Department of Health and Human Services Subchapter b - Food for Human Consumption part 110 -- current good manufacturing practice in manufacturing, packing, or holding human food. 675757 Page 9 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of eight residents (Resident #32) reviewed for infection control. Residents Affected - Few The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #32 on 02/12/2025. This failure could place residents at risk of cross-contamination and development of infections. The findings include: Record review of Resident #32's Face Sheet, dated 02/12/2025, reflected Resident #32 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included Wernicke's encephalopathy (neurological condition caused by deficiency of vitamin B1) and muscle weakness. Record review of Resident #32's Quarterly MDS Assessment, dated 11/13/2024, reflected severe cognitive impairment with a BIMS score of 3. The MDS reflected Resident #32 was incontinent of bowel and bladder, and dependent on staff for toileting needs. Record review of Resident #32's Comprehensive Care Plan, dated 11/13/2024, reflected Resident #32 needs assistance with daily ADL care and one intervention was to assist as needed with incontinent care. An observation and interview on 02/12/25 at 10:15 AM revealed CNA B provided incontinence care for Resident #32. CNA B explained to Resident #32 what she was going to do. CNA B collected care items and washed her hands in Resident #32's restroom. CNA B pulled the drape around Resident #32's bed to provide privacy. CNA B put on clean gloves and loosened the tabs on each side of Resident #32's brief. CNA B used a wipe to clean one side of the labia (part of the female genitalia) with one swipe and dropped the wipe in the wastebasket next to her. CNA B changed gloves without performing hand hygiene and used a clean wipe to clean the other side of the labia. CNA B dropped the wipe in the wastebasket and changed gloves without performing hand hygiene. CNA B used a wipe to clean the vagina (part of the female genital tract) and dropped the wipe into the wastebasket. CNA B removed her gloves, used hand sanitizer, and put on clean gloves. Resident #32 rolled to the right side. CNA B used a clean wipe to clean one side of Resident #32's bottom and changed gloves. CNA B cleaned the other side of Resident #32's bottom and changed gloves. CNA B cleaned between the buttocks, wiping away from the vagina, and changed gloves. CNA B wiped again between the buttocks to ensure the resident was clean. She dropped the wipe and soiled brief into the wastebasket. CNA B removed the soiled gloves, used hand sanitizer, and put on clean gloves. She placed a clean brief under the resident and applied barrier cream on her bottom. CNA B removed her gloves and used hand sanitizer before putting on clean gloves. CNA B secured the tabs on each side of Resident #32's brief and pulled up the sheet to cover the resident. CNA B removed her gloves and washed her hands in Resident #32's restroom. When asked about hand hygiene practice, CNA B stated she should have washed her hands or used hand sanitizer each time she took off the dirty gloves. CNA B stated it was important because it helped prevent spreading bacteria on the resident's body and to other residents. 675757 Page 10 of 11 675757 02/13/2025 Signature Pointe 14655 Preston Rd Dallas, TX 75254

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/12/2025 at 10:28 AM, LVN A stated it was important to prevent the spread of germs during incontinence care because it could cause a UTI (infection in the kidneys or bladder). LVN A stated staff should always sanitize or wash their hands after removing dirty gloves and before putting on clean gloves. In an interview on 02/12/2025 at 10:40 AM, the ADON stated it was important to follow hand hygiene measures and prevent the spread of germs and bacteria to other residents. She stated she would in-service staff. In an interview on 02/12/2025 at 12:20 PM, the DON stated her expectation was for staff to use hand sanitizer or wash their hands before putting on clean gloves and after removing dirty gloves. The DON stated there could be a tiny hole in the glove that was unnoticed. She stated staff could introduce bacteria while providing incontinence care and spread bacteria to the next resident they provided care for. She stated proper hand hygiene was an important infection control measure. Record review of the facility's policy Briefs/Underpads, revised January 2024, reflected when providing incontinence care to Remove gloves, sanitize hands and replace with clean gloves. 675757 Page 11 of 11