Signature Pointe

Inspectors wroteBased on observation, interview and record review the facility failed to post in a form and manner accessible and understandable to residents and resident representatives a list of names, addresses (mailing and email, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 1 of 1 buildings reviewed for postings The facility failed to ensure the number to HHS Long Term Care Regulatory (state survey and certification agency) number for filing grievances, or complaints or suspected violations of state or Federal violations was posted. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 a resident for 4 of 12 residents (Residents #4, #9, #74 and #124) reviewed for care plans. The facility failed to ensure Resident #4, #9 and #124's care plan reflected an intervention which included the bed being in the lowest position and fall mat alongside bed. The facility failed to ensure Resident #74's care plan, dated 02/05/2026, included a care plan for suction use due to the resident was unable to expel any secretion. These failures could place residents at risk of their needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for three of five residents (Resident #8, #74, and #125) reviewed for feeding tube management.1. The facility failed to ensure LVN D checked Resident #8's g-tube placement before flushing and administering medications on 04/15/2026. 2. The facility failed to ensure LVN C checked Resident #74's residual before flushing and medication administration on 04/15/2026.3. The facility failed to ensure LVN A checked Resident #125's g-tube placement before flushing and administering medications on 04/15/2026. These failures could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of twelve (Resident #9, and #74) reviewed for respiratory care. The facility failed to ensure Resident #9 had physician's orders for the use of an oxygen concentrator. The facility failed to ensure Resident #74 had an order for her suction use on 04/14/2026. These failures could place the residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.

Inspectors wroteBased 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 permitted only authorized personnel to have access to the keys for four of eighteen residents (Residents #19, #52, #67, and #79) reviewed for medication storage. 1. The facility failed to ensure Resident #52 did not have a muscle cramp foam inside her room on 04/14/2026. 2. The facility failed to ensure Resident #67's did not have a nasal spray and adaptogenic mushroom inside his room on 04/14/2026. 3. The facility failed to ensure Resident #79 did not have a pain relieving gel inside her room on 04/15/2026. 4. The facility failed to ensure Resident #19 did not have a pain relief ointment inside her room on 04/15/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's main kitchen and two of two substations, reviewed for food and nutrition services. The [NAME] failed to wear a hair net to properly cover her entire head while food was being prepared. The facility failed to properly seal food stored in the freezer. The facility failed to ensure the ice machine and ice scoop, located in the substation on the 4th floor, was thoroughly cleaned. The facility failed to ensure the microwaves in the dining area of the 3rd and 4th floors were properly cleaned. The facility failed to ensure proper pest control in the dining area of the 4th floorThe facility failed to ensure the trashcan in the main kitchen had a lid on it. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each bed have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for seven of fifteen residents (Residents #4, #48, 50, #64, #73, #95, and #100) reviewed for privacy and confidentiality. The facility failed to ensure Residents #4, #48, #50, #64, #73, #95, and #100 had privacy curtains for their privacy. This failure could place the residents at risk of not having their personal privacy maintained while care was provided, which could result in the residents feeling uncomfortable during care and having their personal and medical record exposed to unauthorized individuals.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during personal care and confidentiality of personal and medical records for two of fifteen residents (Residents #48, and #84) reviewed for privacy and confidentiality. The facility failed to ensure Resident #48's door was closed or the privacy curtain was drawn during incontinent care on 04/14/26. The facility failed to ensure that the roommates of residents with AEM had signed consents in the active section of the EHR from Resident #84 or their RP acknowledging the AEM in the shared room since 01/07/2026. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of ten residents (Resident #92 and Resident #10) reviewed for abuse and neglect. The facility failed to ensure Resident #10 was free from abuse when Resident #92 hit him on 03/23/2026. This failure could place residents at risk of abuse and emotional stress.

Inspectors wroteBased on interviews and record review the facility failed to ensure that the transfer or discharge was documented in the resident's medical record for one (Residents #121) of three residents reviewed for transfers and discharges. The facility failed to obtain a signed Against Medical Advice document during Resident #121's discharge on [DATE]. This failure could prevent the resident from receiving necessary information about the resident's support needed for further care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the assessments accurately reflected the resident's status for two (Resident #74 and Resident #110) of ten residents reviewed for accuracy of assessments.1. The facility failed to ensure Resident #74's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter and received suctioning.2. The facility failed to ensure Resident #110's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had a nephrostomy. These failures could place the residents at risk for not receiving care and services to meet their needs, diminished functions of health, and regression in their overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care to one of eight residents (Resident #125) reviewed for baseline care plan. The facility failed to ensure Resident #125 had a baseline care plan after admission to the facility on [DATE]. This failure could place the resident at risk of not receiving necessary care, treatment, and services upon admission that could result to worsen condition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident's environment remained free of hazards as was possible for one of six residents (Resident #73) reviewed for accident hazards. The facility failed to ensure Resident #73 had physician orders for a scoop mattress to ensure it was not a hazard for the resident. This failure could prevent the residents from having an environment that was free from accidents, potential injury, and exposure to toxic chemicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of ten residents (Resident #98) reviewed for pharmaceutical services. The facility failed to dispose of Resident #98's expired insulin on 04/15/2026. This failure could place residents at risk of not receiving the medication's full therapeutic benefits and not receiving medications as ordered resulting to adverse effects.

Inspectors wroteBased 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 two of ten residents (Resident #91 and Resident #82) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene and changed her gloves during Resident #91's incontinent care on 04/14/2026.2. The facility failed to ensure RN B performed hand hygiene before preparing Resident #125's medication on 04/15/2026. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident had the right to receive written notice, including the reason for the change, before the resident's room was changed for 1 of 5 residents (Resident #1) reviewed for room change notifications. The facility failed to ensure Resident #1's Resident Representative was notified of the room change prior to Resident #1 being moved from room [ROOM NUMBER]B to room [ROOM NUMBER]B on 11/03/25. This deficient practice could place the resident at risk of experiencing anxiety and depression about moving to a new environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify, consistent with his or her authority, the resident representative when there was a need to alter treatment significantly for 1 of 5 residents (Resident #1) reviewed for Resident Representative notification of treatment change. The facility failed to ensure Resident #1's Resident Representative was notified of the medication, Tramadol, prescribed to the resident on on 11/18/25. This deficient practice could place the resident at risk of taking medication that may be harmful to the resident.

Inspectors wroteBased on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 6 residents (Resident #1 and #2) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #1's fingernails were trimmed. The facility failed to ensure Resident #2 received her scheduled bed baths for January 2026 and December 2025. These failures could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included:Record review of Resident #1's Face Sheet, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of ten residents (Residents #1, #2, and #3) reviewed for resident rights. The facility failed to ensure the call light system in Residents #1, #2, and #3's rooms were adequately equipped to allow residents to call for staff assistance through a communication system on 11/04/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for eight (Residents #1, #5, #6, #7, #8, #9, #10, and #11) of twelve residents reviewed for privacy and confidentiality. The facility failed to ensure LVN A closed, locked, or minimized her laptop's monitor and did not leave Residents #1, #5, #6, #7, #8, #9, #10, and #11's medical information exposed and unattended on top of the nurse's cart on 12/03/2025. This failure could place the residents at risk of their medical information being accessed by unauthorized individuals.

Inspectors wroteBased 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 permitted only authorized personnel to have access to the keys for three (Residents #2, #3, and #4) of ten residents reviewed for medication storage. 1. The facility failed to ensure a tube of zinc oxide (cream used to treat skin irritations, diaper rash, and other skin conditions) was not left in Resident #2's room on 12/03/2025. 2. The facility failed to ensure a tube of zinc oxide was not left in Resident #3's room on 12/03/2025. 3. The facility failed to ensure tubes of zinc oxide and a container of wound cleanser were not left in Resident #4's room on 12/03/2025. 4. [...]

Inspectors wroteBased 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 two (Resident #1 and Resident #2) of twelve residents reviewed for infection control. 1. The facility failed to ensure CNA E performed hand hygiene during Resident #1's incontinent care on 12/03/2025. 2. The facility failed to ensure LVN C wore a gown for EBP while disconnecting Resident #2's IV on 12/03/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #4) reviewed for dignity. The facility failed to conceal Resident #4's gall bladder bag lying in public view. This failure placed residents at risk of not having their right to a dignified existence and self-determination maintained.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nurse call system was assessable for three of six residents (Resident #1, #2, and #3) reviewed for call systems access. The facility failed to ensure the call light system in Resident #1, #2, and #3's rooms was in a position that was accessible to the residents on 10/02/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergencyFindings include: 1. Record review of Resident #1's Face Sheet, dated 10/02/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnosis included lack of coordination. Record review of Resident #1's Quarterly MDS assessment, dated 9/29/25, reflected a BIMS score of 00 (severe cognitive impairment). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for two of six residents (Resident #5 and #6) reviewed for restraints. The facility failed to ensure Resident #5 and Resident #6 had physician orders for the bolster mattresses on their beds. This failure could prevent the residents from having an environment that was free from physical restraints.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #6) reviewed for respiratory care. The facility failed to ensure Resident #6's nebulizer mask was properly stored in a bag when not in use on 10/02/25. This failure could place the resident at risk for respiratory infection and not having his respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one of five residents (Resident #1) reviewed for Reasonable Accommodation of Needs.1. The facility failed to ensure the call light system in Resident #1's room was in a position that was accessible to the resident on 8/12/25. 2. The facility failed to ensure Resident #1 had a call light system that accommodated her physical limitation. These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for one of five residents (Resident #2) reviewed for physical restraints. The facility failed to ensure Resident #2 had physician orders for the for the bolster pads (bed padding) attached to the mattress on her bed. This failure could failure could place residents at risk of not having an environment that was free of restraints which could result in injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the confidentiality of the residents personal and medical records for five (Residents #3, #4, #5, #6, and #7's) of five residents reviewed for Privacy and Confidentiality. The facility failed to ensure LVN C did not leave Residents #3, #4, #5, #6, and #7's medical information exposed and unattended on top of the nurse's cart on 05/08/2025. This failure could place the residents at risk of their medical information being exposed to unauthorized individuals.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #1, Resident #2 and Resident #3) of five residents reviewed for respiratory care. The facility failed to ensure Residents #1, #2, and #3's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) were properly stored when not in use on 05/08/2025. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in a locked cart or under direct observation of authorized staff in an area where residents could access it for one (Wound Care Cart) of one cart reviewed for pharmacy services. The facility failed to ensure that the wound care cart was locked when not in use on 05/08/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, for 2 of 4 medication carts (3rd floor) and 2 of 2 medication refrigerators (2nd and 3rd floor) reviewed for medication storage. 1. The facility failed on 06/06/24 to ensure the 2nd floor medication refrigerator was free of discharged residents' narcotic medications and kept narcotic sheet record. 2. The facility failed on 06/06/24 to ensure the 3rd floor medication cart and medical refrigerator was free of discharge residents' expired medication and discounted medications (medications that residents were no longer taking). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access for 1 (3rd Floor Treatment Cart) of 2 Treatment Carts, 2 (340 Hall Nurses Medication Cart and 200 Hall Nurse Medication Cart) of 8 Nurses Medication Carts reviewed for medication storage. The facility failed to ensure the 3rd floor Treatment Cart was locked when not in use. RN A and MA B, who shared the 340 Hall Nurses Medication Cart, on the 3rd Floor, failed to ensure it was locked. LVN C failed to ensure the 200 Hall Nurse Medication Cart, on the 2nd Floor - Secured Unit, was locked. These failures could affect residents by placing them at risk of ingestion/exposure to medications not intended for them and drug diversion.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #24) of five residents reviewed for pressure ulcers. The facility failed to appropriately identify Resident #24's skin injury, obtain, and provide appropriate treatment. The facility failed to notify the physician of Resident #24's new facility acquired wound to the left buttock and the deep tissue injury to the left heel. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two residents (Resident #1, and Resident #2) of ten residents reviewed for care plans. The facility failed to create a care plan addressing Resident #1's behaviors. The facility failed to create a care plan addressing Resident #2's PTSD and anger outbursts. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the necessary services for residents who were unable to carry out the activities of daily living to maintain good grooming and personal hygiene for 3 (Residents #35, #42, #312) of 11 residents reviewed for ADL care. The facility failed to ensure Residents #35, #42, and #312 were shaved and hair was combed. The facility failed to document Resident #42's refusal for hygiene care including shaving and interventions, in his nurse progress notes. These failures could place residents at risk of losing their dignity and self-worth making them susceptible to skin and scalp infections which could lead health decline and decreased psycho-social well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to treat residents with respect and dignity for one (Resident #92) of 11 residents reviewed for resident rights. The facility failed to ensure Restorative Aide (RA) I did not stand over Resident #92 while assisting the resident with her meal in the 300-hall dining room. This failure could affect residents who require assistance with activities of daily living and place them at risk of feeling rushed to eat or not interested in eating which could result in weight loss and decreased psycho-social well-being.

Inspectors wroteBased on observation, interviews and record review, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff for one (Resident #42) of 11 residents reviewed for call lights. The facility failed to ensure Resident #42's had a call light device. The facility failed to ensure the call light panel system in Resident #42's room worked. These failures could place residents at risk of not receiving care when requested which could cause a delay in care and services which could result in injury and decline in health and psycho-social well-being.