Health inspection·August 8, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 1 of 4 nurses' medication carts (medication cart on 200 hall) reviewed for pharmacy services. The facility failed to discard expired glucometer control solution (used to test and calibrate the glucometer machines) from 200 hall medication cart. This failure placed the residents at risk of incorrect labeling of drugs and biologicals. Findings included. During an observation and interview on [DATE] at 10:15 AM, RN B identified the 200 hall nurse's medication cart. The cart contained a box of control solutions used to calibrate two glucometers which were also stored in the cart. No other control solutions were found within the cart. The box of control solutions reflected an expiration date of [DATE]. No open date was noted on the box. RN B stated he was unaware of the expired control solutions and it was the responsibility of the 10 pm to 6 AM nurse to use the solutions to calibrate the glucometers daily. RN B stated the risk for using expired control solutions included decreased efficacy of the solutions could make the calibration inaccurate which could lead to inaccurate results when testing resident's glucose levels. RN B provided the control logs completed by the 10 PM to 6 AM nurse. During an interview on [DATE] at 10:51 AM, the DON stated the 10:00 PM to 6:00 AM nurses were responsible for calibrating the glucometers on their carts. She stated she, the charge nurses, and the ADON were responsible for ensuring the calibrations were completed and items in the medication carts were up to date. She stated she was surprised to hear about the expired control solution and stated the pharmacy consultant also checked the carts. The DON checked the cart with RN B who showed her the expired solution. He had marked the box as DO NOT USE. The DON instructed RN B to retrieve new test strips and control solutions, re-calibrate the glucometers, and re-test the residents. She stated the risk of using expired solutions for calibration was inaccurate glucose readings when testing residents. On [DATE] at 2:51 PM, attempt to conduct a telephone interview with LVN C , who worked the 10:00 PM to 6:00 AM shift and signed the Glucometer Daily Quality Control Record on [DATE] through [DATE] and [DATE] through [DATE] was unsuccessful. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 676143 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)