LONGVIEW, TX - Federal inspectors issued an immediate jeopardy citation to Longview Hill Nursing and Rehabilitation Center after discovering that nursing staff administered expired insulin medications to diabetic residents and systematically failed to communicate critical health changes to physicians.
The February 14, 2025 complaint inspection revealed violations so severe that regulators determined residents faced immediate risk of serious injury, illness, or death. The facility was found to have compromised the safety of multiple diabetic residents through medication management failures and communication breakdowns that could have resulted in life-threatening complications.
Expired Insulin Found Throughout Facility
Inspectors discovered expired insulin medications stored in medication carts across the facility, with some vials exceeding manufacturer expiration guidelines by up to 13 days. During the morning medication round on February 13, Licensed Vocational Nurse E was observed preparing to administer Novolog insulin to a diabetic resident from a vial that had been opened 31 days earlier - three days beyond the 28-day safety limit.
The resident's blood sugar level measured 335 mg/dL, significantly above normal ranges of 80-130 mg/dL. When the nurse was questioned about the expired insulin, she immediately recognized the violation and sought replacement medication from emergency supplies on another unit.
Additional violations were documented for four other diabetic residents. One resident's Humalog insulin had been opened 32 days earlier, while another resident had both Insulin Aspart and Lantus vials that were 40-41 days past their opening dates. A fourth resident's Lantus vial contained no opening date despite having a designated space for this critical safety information.
Medical Risks of Expired Insulin
Insulin effectiveness decreases significantly when stored beyond manufacturer recommendations. According to FDA guidelines, insulin maintains optimal potency when refrigerated but can be stored at room temperature for up to 28 days before losing effectiveness. Extended exposure to temperature variations or storage beyond recommended timeframes can result in unpredictable blood sugar control.
For diabetic residents, ineffective insulin can lead to dangerous blood sugar spikes, potentially causing diabetic ketoacidosis, a life-threatening condition requiring immediate medical intervention. Conversely, if insulin potency varies unpredictably, residents could experience dangerous drops in blood sugar levels, leading to hypoglycemic episodes that can cause confusion, falls, seizures, or coma.
The facility's own medication administration policy required staff to check expiration dates, write opening dates on containers, and refer to shortened expiration date tables. These protocols existed specifically to prevent the medication safety failures documented during the inspection.
Communication System Failures
Beyond medication management issues, inspectors identified systemic failures in how nursing staff communicated resident health changes to physicians. The immediate jeopardy citation encompassed broader quality of care concerns where critical health information was not being properly documented, reported, or addressed.
The facility's corrective action plan revealed the scope of communication problems. Staff required retraining on documentation in medical records, medication administration protocols, notification policies for changes in medication administration, wound care procedures, and reporting abnormal radiology results.
Licensed nurses were not consistently giving shift reports based on the facility's electronic health record system, and staff were failing to review laboratory and radiology results during shift changes to ensure physicians received timely notifications of critical findings.
Industry Standards and Expected Protocols
Federal nursing home regulations require facilities to ensure that residents receive necessary pharmaceutical services to maintain health and prevent disease. This includes proper medication storage, handling, and administration procedures that protect resident safety.
Standard protocols require nursing staff to verify medication expiration dates before administration, properly label opened medications with opening dates, and maintain temperature-controlled storage conditions. When medications expire or lose potency, staff must immediately remove them from circulation and obtain fresh supplies.
Communication protocols should ensure that any changes in resident condition are promptly evaluated, documented, and reported to attending physicians. This includes medication-related issues, wound care concerns, laboratory abnormalities, and any other health developments that could impact resident care.
Immediate Corrective Actions Required
Upon identifying the immediate jeopardy conditions, facility administrators implemented emergency corrective measures. All nursing staff received immediate retraining on medication administration, documentation requirements, and physician notification protocols. The facility evaluated every resident for condition changes and verified that no additional safety concerns existed.
Administrative oversight was enhanced with daily review procedures for medication administration, clinical documentation, and physician communication. The Administrator began attending morning clinical meetings to ensure proper oversight of health status reporting and physician notifications.
Weekend supervisors received additional responsibilities for reviewing laboratory and radiology results to ensure continuous physician communication outside regular weekday schedules. The facility convened an emergency Quality Assurance and Performance Improvement meeting with the Medical Director and Regional Clinical Specialist to address the immediate jeopardy concerns.
Regulatory Response and Ongoing Monitoring
Federal surveyors returned on February 14 to verify that corrective measures adequately addressed the immediate jeopardy conditions. After confirming that staff demonstrated competency in medication administration and communication protocols, regulators determined that immediate resident safety threats had been resolved.
However, the facility remains under heightened scrutiny with ongoing compliance monitoring requirements. Staff competency will be continuously evaluated, and the facility must demonstrate sustained improvement in medication management and clinical communication practices.
The violation classification was reduced from immediate jeopardy to a pattern-level citation with potential for more than minimal harm, indicating that while immediate threats were addressed, systematic improvements must be maintained and proven effective over time.
This case highlights the critical importance of medication safety protocols in nursing homes, where residents often depend on complex medication regimens to manage multiple chronic conditions. For diabetic residents particularly, precise medication administration and monitoring can mean the difference between stable health management and life-threatening complications.
The inspection findings underscore the need for robust quality assurance systems that ensure medication safety, proper clinical documentation, and effective communication between nursing staff and physicians. These fundamental care processes form the foundation of safe, quality nursing home care that residents and families have the right to expect.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Longview Hill Nursing and Rehabilitation Center from 2025-02-14 including all violations, facility responses, and corrective action plans.
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