Mid Valley Nursing & Rehabilitation

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

for the OOH DNR form to be signed by the doctor because it makes the document official, a legal document that all parties signs. The Social Services stated the DNR was not complete until the doctor signed it. During an interview [DATE REDACTED] at 2:00 pm with DON stated that the social worker was responsible for completing the OOH DNR form. She stated the facility explains the document and if they say yes that they want to be DNR, the facility would obtain the resident/RP and witnesses signatures. DON said that she got

a verbal order from the MD and that was why the code status was changed to DNR. DON said that there was not a negative outcome because she had the verbal order. Record review of the facility's Advanced Directives policy date reviewed/revised [DATE REDACTED], revealed the Advance directive implementation: the IDT should honor the care decision expressed and initiate the advance directive by initiating the out of hospital Do Not Resuscitate (OOH DNR) form and should obtain the medical provider/physician's signature as per

the OOH DNR form instructions.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mid Valley Nursing & Rehabilitation

601 N Mile 2 West Mercedes, TX 78570

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)

F 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 1 of 3 residents reviewed for intravenous fluids. (Resident #1) The facility failed on 12/29/2025 to ensure the dressing on Resident #1's peripheral intravenous line (a short flexible tube inserted into the vein to administer fluids and medications) was dated and initialed. This failure could place residents at risk of not receiving the appropriate IV care and services.

Findings included: Record review of Resident #1 face sheet dated 12/31/2025 revealed an [AGE] year-old female admitted to facility on 12/11/2025 with diagnosis of Diabetes Mellitus type 1 (a chronic autoimmune disease where the immune system mistakenly destroys the insulin-producing beta cells in the pancreas, leading to little or no insulin production, causing high blood sugar), Muscle wasting and atrophy, dehydration (your body doesn't have enough water and fluids to function properly). Record Review of Resident #1 comprehensive care plan dated 12/26/2025 revealed Resident #1 is at risk for complications associated with intravenous therapy related to peripheral line, with interventions frequently monitor/check IV access site upon each care encounter, careful when providing care & look for s/s of infection or infiltration (abnormalities) such as redness, swelling, puffiness, pain, discomfort, tenderness, drainage, warm to touch at or near the site. If any abnormalities are noted, then promptly notify Nurse /MD/NP. Record review of Resident #1's MDS assessment dated [DATE REDACTED] reflected he scored a 5 on his BIMS which reflected severely cognitively impaired. During an observation on 12/29/2025 at 9:30 am Resident # 1 had a peripheral intravenous lock covered with a transparent dressing with no date and no initials on her right hand. There were no signs or symptoms of infection or infiltration noted at the IV site. During an interview on 12/29/25 at 9:25 a.m. LVN A stated she was the nurse for Resident #1. She stated that the nurse who initiated the IV was responsible for labeling the dressing with the date of placement and initials. LVN A stated that it was important to label the IV site to know when the IV was placed or the last time it was changed. She stated that if the IV was changed within the ordered time, then it could cause an infection. She stated that the last time he had checked the resident's IV site was this morning, at the beginning of his shift. LVN A stated that

the IV site should be checked at every shift. The site was to be checked for any signs of infection, the date and signature on the dressing, and check that the saline lock cap was in place. She stated he could not recall when the last training was he had received on IV administration. LVN A stated the resident had a peripheral IV lock on her right hand covered with a transparent dressing that was not labeled or dated. In an

interview on 12/31/25 at 2:00 p.m., the DON stated she did not know why the dressing label had not been dated and initialed. The DON stated that the nurse that had inserted the IV should have dated and initialed

the dressing that was over the IV site. The DON searched through orders on their computer system to verify who had placed the IV, however, she was able to find the progress note indicating placement. The DON stated that labeling the insertion site dressing was taught in nursing school and every nurse should have known to label it. She stated that the negative outcome of not labeling the dressing was that it could go over

the recommended standard time of every 72 hours and could cause infection. She stated that IV administration class was done annually and as needed. Record review of facility policy named IV Policies and Procedures Manual revealed: Procedure: 12. With sterile tape, secure the catheter and apply dressings. Label appropriately.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/31/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mid Valley Nursing & Rehabilitation

601 N Mile 2 West Mercedes, TX 78570

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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 residents (Resident #1) reviewed for medication storage.

The facility did not ensure a medication named Normal Saline flush was not stored at the bedside for Resident #1 on 12/29/2025. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: Record review of Resident #1 face sheet dated 12/31/2025 revealed an [AGE] year-old female admitted to facility on 12/11/2025 with diagnosis of Diabetes Mellitus type 1 (a chronic autoimmune disease where the immune system mistakenly destroys the insulin-producing beta cells in the pancreas, leading to little or no insulin production, causing high blood sugar), Muscle wasting and atrophy, dehydration (your body doesn't have enough water and fluids to function properly).

Record review of Resident #1's MDS assessment dated [DATE REDACTED] reflected he scored a 5 on his BIMS which reflected severely cognitively impaired. Record Review of Resident #1 comprehensive care plan dated 12/26/2025 revealed Resident #1 is at risk for complications associated with intravenous therapy related to peripheral line, with interventions frequently monitor/check IV access site upon each care encounter, careful when providing care & look for s/s of infection or infiltration (abnormalities) such as redness, swelling, puffiness, pain, discomfort, tenderness, drainage, warm to touch at or near the site. If any abnormalities are noted, then promptly notify Nurse /MD/NP.During an observation and interview on 12/29/2025 at 9:30 am Resident # 1 was observed with a normal saline flush on his television stand. She stated the nurse left the normal saline flush on top of the television stand. During an interview on 12/29/2025 at 9:35am with LVN A said no resident should have medications or the normal saline flush at their bedside. She said a resident could take the normal saline, other residents or visitors. She said residents could have an allergic reaction or the normal saline flush could get contaminated. During an

interview 12/31/2025 at 2:00 pm with DON said no resident should have medication of any kind at their bedside. She said another resident could go in the room and take the medication. She said Resident #1 could get an adverse reaction. Record Review of facility policy titled Medication Cart Use and Storage revealed: Security: the medication cart and its storage should be kept closed, secured and/or in the line of sight when not in use.

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Facility ID:

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