Health inspection·September 6, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 6 of 20 rooms (Rooms 330, 340, 602, 704, 707, and 710) and 3 of 6 carts (300 Hall, 500 Hall, and 700 Hall) reviewed for accidents and hazards. The facility failed to identify a process to ensure sharps containers for Rooms 330, 340, 602, 704, 707 and 710 and carts for 300 Hall, 500 Hall, and 700 Hall were monitored and changed before they became overfilled. This failure could place residents at risk of exposure to bloodborne pathogens. Findings included: Observations on 09/04/24 between 9:35 AM and 10:30 AM revealed Rooms 330, 340, 602, 704, 707 and 710 and nurse medication carts for 300 Hall, 500 Hall and 700 Hall were observed to have sharps containers (used to stored disposed syringes) that were filled past the Fill Line, which prevented the disposal flaps from closing properly. Interview on 09/04/24 at 10:50 AM, LVN A stated sharps containers in resident rooms were the responsibility of the ADONs, and sharps containers on the medication carts were the responsibility of the individual nurse assigned that cart. LVN A stated she did not know how long her cart's (500 Hall) sharps container had been over filled. She stated the risk of an overfilled sharps container was exposure to a used sharps. Interview on 09/04/24 at 11:00 AM, LVN B stated sharps containers on the nurse medication carts were the responsibility of the nurse. Sharps containers in the resident rooms were the responsibility of everyone. She stated the risk of an over filled sharps container was getting poked by a used needle. Interview on 09/04/24 at 11:05 AM, the ADON stated the nurses were responsible for all sharps containers and changing them out. The ADON stated anyone could identify a sharps container that needed to be changed and notify the nurse or herself. She stated the risk of an overfilled sharps container was exposure to used sharps. Interview on 09/04/23 at 11:20 AM, the DON stated changing out sharps containers was the responsibility of all nursing staff. He stated he was unaware of the fill line on the sharps container and would begin to educate staff immediately. He stated the risk of an overfilled sharps container was (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 2 Event ID: 676358 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 676358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062 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)