Balch Springs Nursing Home

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain documentation that the residents representative has been delegated the necessary authority to exercise the resident's rights and must verify that a court-appointed representative has the necessary authority for the decision-making at issue as determined by the court. For example, a court-appointed representative might have the power to make financial decisions, but not health care decisions. Additionally, the facility must make reasonable efforts to ensure that it has access to documentation of any change related to the delegation of rights, including a resident's revocation of delegated rights, to ensure that the resident's preferences are being upheld for 1 (Resident #13)of 5 residents (Resident #32, #40, #77, and #80) reviewed for resident representative rights. [...]

Inspectors wroteBased on interview and record review 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 for the residents through the means other than a postal service for 6 (confidential residents) of 75 residents reviewed for rights to forms of communication with privacy. The facility failed to deliver mail to the residents within twenty-four hours of delivery on premises or the facility's post office box according to their policy. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life.

Inspectors wroteBased on interview and record review the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 1 resident (Resident #8) of 5 reviewed for notifying the LTC Ombudsman of the residents' discharge. The facility failed to ensure Resident #8 was not discharged on 04/13/2026 without a notice to the LTC state ombudsman. This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #55) reviewed for PASRR assessments. The facility failed to ensure Resident #55 was referred to the appropriate state-designated mental health authority for review when she received a new diagnosis of schizoaffective disorder, bipolar disorder and anxiety disorder. This failure could place residents at risk of not being evaluated and receiving needed PASRR services.

Inspectors wroteBased on observations, interviews, and record reviews 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 (Resident #18) of five residents, reviewed for infection control. 1. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #18 and changed her soiled gloves before placing items in her pocket. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 14 residents reviewed for pressure ulcers. The facility failed to address Resident #1 required off-loading of heels and repositioning every two hours. Resident #1 developed a Stage 4 Pressure Wound. On 03/25/2026 at 6:22 p.m. an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 6:22 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of 14 residents, reviewed for care plans. The facility failed to address Resident #1's required off-loading of heels and repositioning every two hours, as these orders were not reflected in Resident #1's Comprehensive Care Plan. Resident #1 developed a Stage 4 Pressure Wound. On 03/25/2026 at 6:22 p.m. an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 6:22 PM. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were accurately labeled and dated with the received or expiration date. 2. The facility failed to ensure dented cans were placed in a separate storage area. 3. The facility failed to ensure opened items were sealed or resealed effectively. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of dry storage on 03/04/2025 at 9:13am revealed the following: -1, 1lbs box of cream of wheat dated 02/08/2025 opened and exposed to the air. - 6 bags of hot dog buns with no use by or expiration date. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to promote healing and to prevent further development of skin breakdown or pressure ulcers for two (Resident #10 and Resident #32) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #10 was repositioned every two hours as indicated in Resident #10's physician orders. 2. The facility failed to ensure Resident #32 was repositioned every two hours as indicated in Resident #32's care plan. These failures could place residents at risk for worsening pressure ulcers, new pressure ulcers, or infection.

Inspectors wroteBased on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon for two (Residents #19 and Resident #9) out of six residents and failed to ensure the Pharmacist Consultant reported irregularities to the Physician whose medications were reviewed. 1. Resident 19's Pharmacist consultant recommendation for a gradual dose reduction of Citalopram (antidepressant medication) had no physician rationale for continued use. 2. Resident 19's Pharmacist consultant recommendation for a gradual dose reduction of Quetiapine (antipsychotic medication) had no physician rationale for continued use. 3. Resident 9's Pharmacist consultant recommendation for a gradual dose reduction of Risperidone (antipsychotic medication) had no physician rationale for continued use. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles for one (200 hall medication cart) of three medication carts reviewed for medication labeling. The facility failed to ensure two insulin pens (one Aspart insulin syringe and one Tresiba insulin syringe) on the 200 hall medication cart had open dates. The facility failed to ensure two insulin pens on the 200-hall medication cart were discarded 28 days after being opened. One Lyumjev insulin pen and one Admelog insulin pen had an open date of 1/20/2025 and was found in the cart on 3/04/2025 (46 days after being opened). These failures could place residents at risk for not receiving the intended therapeutic effects of prescribed medication.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight for one (Resident #99) of seven residents reviewed for nutrition. 1. The facility failed to complete an annual comprehensive nutritional assessment or a nutrition assessment after identified weight loss by the dietician on 8/12/2024 per facility policy. 2. The facility failed to implement dietary recommendations on 8/12/2024 that included ordering a magic cup and obtaining weekly weights for four weeks. These failures could place residents at risk for unplanned weight loss and place them at risk of not having their nutritional needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident f The facility failed to document that Resident #1 was given insulin on 08/20/24, 08/21/24, 08/23/24. This failure could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of four (Medication Cart #1) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended on 05/24/24. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on interviews and record reviews, the facility failed to conduct and document a completed facility-wide assessment which included a current (EPP) Emergency Preparedness Plan to determine what resources were necessary to care for its residents competently during emergencies as necesarry and at least annually for one (facility) of one facility reviewed for Emergency service planning. The facility failed to review, revise and update their Emergency Preparedness Plan at least annually; the most current EPP was not in the EPP binder. And after inquiry on 02/14/24, the Administrator provided the surveyor a four-page EPP dated 01/17/23 by former Administrator G that was unsigned by anyone and without proof of all of the completed employee trainings and drills. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for two (Hall 200, and 300) of four halls observed for environment. The facility failed to ensure bathrooms on Hall 200 and 300, were clean, safe, and in good repair. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all assistive devices and overbed tables were maintained and free of hazards for five (Residents #10, #12, #19, #35 and #44) of eighteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #10, #12, #35 and #44. The facility failed to properly maintain overbed tables for Resident #19. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Residents #53, #57, and #174) of 6 residents reviewed for infection control. 1. CNA D failed to put on PPE prior to entering three contact isolation rooms to serve the lunch trays. 2. CNA D failed to disinfect her hands while servicing food trays to the residents on Hall 100. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for hall 300, entry to the dining area, and one out of four resident door knobs not repaired that was observed for environment The facility failed to ensure the floor between room [ROOM NUMBER] and 309, and the right side entryway into the dining room . and the and door handles were in good repair. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #53) of 1 resident's reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #53 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for 1 (one medication cart for Hall 100) of 6 medication carts. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when LVN A's one medication cart for Hall 100, was left unlocked and unattended by LVN A. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion.