Midway Neurological / Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the immediate availability of essential emergency resuscitation equipment for a resident designated as Full Code. Specifically, staff did not have an ambu bag (manual resuscitation device) readily available when a resident was identified as unresponsive and not breathing during a Code Blue event. This deficient practice affected one of three residents (R3) reviewed for cardiopulmonary resuscitation (CPR). As a result, staff were unable to immediately provide rescue ventilations while CPR was initiated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect R2's right to remain free from physical abuse from another Resident (R3). This affects 2 of 3 residents (R2, R3) reviewed for abuse in the sample of 3. This failure resulted in R3 striking R2 with a wheelchair leg rest, causing multiple injuries including two fractures to the left hand, lacerations to the left arm, a mild brain bleed, a collection of blood in the lung, rib fractures, and a facial fracture. Findings Include:R3 is no longer lives in the facility. R2 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including encephalopathy, cerebral infarction, epilepsy, heart failure, osteoarthritis, dementia, anxiety, hypertension, major depressive disorder, and hemiplegia. R2's Brief Interview for Mental Status (BIMS) score was 6 (dated 3/9/2026). [...]

Inspectors wroteBased on interviews and record review, the facility failed to follow their Abuse Prevention Program by not implementing the care planning process, not identifying any problems, goals, and approaches which would reduce the chances of mistreatment for 4 residents (R1, R2, R3, R4) out of 4 residents reviewed for abuse. On 5/21/2026 at 2:02 P.M., V12 (Social Service Director) stated an abuse care plan should be included in a resident's comprehensive care plan. V12 stated an abuse care plan should be added for new residents, a significant change in status, revised and updated as necessary. V12 stated R1, R2, R3, and R4 did not have an abuse care plan implemented in their comprehensive care plan. V12 states it is expected that the residents have an abuse care plan. V12 states R2s care plan should have been in place after R2 sustained multiple injuries from R3. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a second witness signature for psychotropic medications consent prior to administration of psychotropic medications and failed to ensure resident signature was obtained prior to administration of psychotropic medication. These failures affected two (R1 and R2) residents reviewed for residents' rights to be informed in the total sample of five residents.

Inspectors wroteBased on interview and record review the facility failed to accurately assess a critical clinical sign (Battle sign) and implement their change in condition policy by failing to immediately activate EMS (emergency medical services) 911 to transport a resident with an acute change in mental status. This affected one of three residents R366 reviewed for change in condition and delay of treatment. This failure resulted in R366 being transported to the hospital and diagnosed with a large traumatic subdural bleed (collection of blood between the covering of the brain and the surface of the brain) with midline shift (displacement of the brain tissue across the midline) causing herniation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the residents had a table to sit their food tray on to eat their meals. This affects eight of eight residents (R363, R303, R247, R22, R31, R466, R186, R245) reviewed for accommodations of needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's code status was readily accessible to staff by not having the code status documented on the face sheet or in the paper chart/ clinical record. This affected five of five residents (R616, R617, R618, R619 and R166) reviewed for advanced directives. Findings Include: R616 was admitted on [DATE]. R616's face sheet section titled advance directive did not document a code status, it was blank. R616's physician order sheet dated 5/30/25 documents: Full code On 6/11/25 at 4:25pm, R616's entire paper chart was reviewed. No advance directive paperwork was included to indicate R616's code status. The code binder on R616's unit documents: no residents on the do not resuscitate list (DNR) list. V17 (nurse) said, R616's code status was not in his paper chart. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to label all insulin pens and inhalers with open and expiration dates. This affects four of four residents (R154, R261, R60 and R191) reviewed for medication labeling and storage.

Inspectors wroteBased on interviews and records reviewed the facility failed to provide effective interventions to prevent a resident-to-resident physical assault. This affected two of three residents (R568, R277) reviewed for physical abuse. This failure resulted in R277 being assaulted by R568 sustaining a discoloration to his left eye.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident medication regimen was free from an unnecessary medication by administering one Quetiapine Fumarate 400MG (milligram) tablet without a physician order and failed to reevaluate the use of a psychotropic medications use at least every 14 days. This affected two of five residents (R7, R333) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of care to administer and obtain a physician order prior to administering medications. This affected two of two residents (R188 and R7) reviewed for professional standards of care, physician orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for hand splint and failed to ensure a fabricated right foot orthosis was ordered for a resident with a diagnosis of right drop foot, significant varus of the ankle, weakness of the knee extensor musculature and notable wrist drop, along with weakness of the wrist extensor muscles. This affected one of five resident (R215) reviewed for restorative services.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one resident who is incontinent of bladder receives appropriate treatment and services to prevent/ reduce the risk of urinary tract infections. This affects one of three (R239) residents reviewed for infections in a sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5%, by making 3 errors out of 30 attempts with an error rate of 10 %. This affects two of six residents (R7 and R188) reviewed for medication errors.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the attending physician of an abnormal lab result for 3 days after recieving the result. This affected one of three residents (R239) reviwed for abnormal lab results notificaton.

Inspectors wroteBased on interview and record review, the facility failed to follow their change in condition policy and did not notify a family member of a resident's (R2) change in condition and need to be sent out to the hospital for one (R2) out of four residents reviewed for change in condition in a total sample of seven. Findings Include: R2 is a [AGE] year old with the following diagnosis: psychosis, mood disorder, suicidal ideation, and anxiety disorder. A Social Service note dated 3/27/25 documents R2 became verbally and physically aggressive with staff. R2 attempted to go to the patio but the patio was currently closed. Staff redirected R2 back to R2's assigned unit, but R2 refused. R2 became increasingly agitated R2 then attacked staff by slapping them and kicking them in the stomach. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their physician services policy and ensure the attending physician conducted face-to-face visits with residents within the first 30 days of admission/re-admission and/or at least once every 60 days. This affected four of four residents (R1, R4, R5, R6) reviewed for physician visits.

Inspectors wroteBased on interview and record review, the facility failed to schedule outside appointments and testing for one resident (R1) out of three residents reviewed for resident rights in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by failing to report an alleged violation involving a resident-to-resident sexual abuse after being notified of the allegation. This failure affected one (R1) of one residents reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility staff failed to 1. wear a hair restraint to cover a beard while in the kitchen, 2. failed to maintain sanitizing solution at 200 ppm (parts per million) of Quaternary Ammonium solution for dishes in the three-compartment sink, 3. failed to label and date food in the refrigerator. 4. failed to clean and sanitize the blender equipment and spatula after preparation of puree meal. This failure has the potential to affect all 357 residents who received oral meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to refrigerate unopened medication that required refrigeration before opening for 2 of 30 (R60, R73) residents reviewed during medication storage and labeling task. Findings Include: On 07/15/24 at 08:25 AM inspected the medication cart from the second floor. V9 (Licensed Practical Nurse/LPN) present during the inspection, found an unopened medication requiring to be refrigerated before opening, placed in the medication cart. Items found: R60's Lantus, two 22 units pens, labeled refrigerate before opening, stored in medication cart at room temperature unopened. R73's Novolin R 100unit/ml, one 10ml vial, labeled refrigerate before opening, stored in medication cart at room temperature unopened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provide timely assessment and adequate intervention for a resident who was experiencing complications with an indwelling urinary catheter. This failure affected one (R2) of two residents reviewed for urinary catheter care. This failure resulted in R2 experiencing a delay in assessment and treatment while experiencing a leaking urinary catheter, abdominal fullness, and pain before being transferred to hospital and being treated for urinary retention secondary to malfunctioning urinary catheter and (UTI) urinary tract infection.

Inspectors wroteBased on interview and record review, the facility failed to follow their resident discharge policy by failing to document a discharge summary and plan of care for a resident who was hospitalized for destructive behaviors and did not return to the facility. This failure applied to one (R5) of one resident reviewed for discharge procedures.

Inspectors wroteBased on interview and record review the facility failed to develop an individualized plan of care for a resident identified to be at risk for aspirations and assessed to have impairments while eating. The facility also discharged resident from speech therapy before reaching the short-term goals identified in evaluation. This affected one of one resident (R13) reviewed for safe oral intake. This failure resulted in R13 becoming unconscious, CPR (cardiopulmonary resuscitation) being initiated, excessive amount of food found in R13's airway, and resident being admitted to hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, implement, evaluate, and reevaluate a plan to prevent a continued insidious unplanned weight loss for one of three residents (R14) reviewed for unplanned weight loss. This failure resulted in R14 having a continued weight loss resulting in a significant weight loss of 18.55% in 90 days.

Inspectors wroteBased on interview and record review the facility failed to prevent incidents of staff to resident verbal/mental abuse. This affected four of four (R10, R21, R22, R23) residents reviewed for abuse.

Inspectors wroteBased on interviews and records reviewed the facility failed to report an allegation of abuse to state surveying agency. This failure affected 4 of 4 (R21-R24) residents reviewed for abuse reporting.

Inspectors wroteBased on interview and record review the facility failed to have an effective smoking policy and contraband policy to prevent unauthorized items/smoking material. This affected on two of three (R3, R7) residents reviewed for safety and supervision. This failure resulted in R3, a resident with visual impairment and assessed to require supervision while smoking, to bring unauthorized smoking material from a home visit and drop a lit cigarette into a garbage can causing a fire. This has the potential to affect 84 residents on the fifth floor.

Inspectors wroteBased on interviews and records reviewed the facility failed to notify 1 resident (R11) of 3 in writing prior to performing a room change.

Inspectors wroteBased on interview and record review the facility to prevent the loss of a resident's funds during a room change. This affected one of three residents (R11) reviewed for misappropriations of funds.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop appropriate interventions to prevent a resident from pulling out his gastrostomy tube (GT) numerous times that required visits to the hospital. This deficiency affects one (R127) of three residents in the sample of 39 reviewed for Tube Feeding Management.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Intramuscular Medication Administration policy by failing to withdraw the plunger to check for blood return. This deficient practice affects 1 resident (R31) of 5 residents reviewed for medication administration in a total sample of 39 residents. Findings Include: On 9/27/23 at 8:45 AM, medication administration observation conducted with V19 (Licensed Practical Nurse/LPN). R31 has PO (by mouth) and IM (Intramuscular) injection medication scheduled for 9:00 AM. R31's IM injection medication of Fluphenazine Decanoate 25 MG/ML, to inject 2ml (50mg) IM once monthly-chart and rotate site. V19 prepared the medication in 12mL syringe with 21 gauge with 1 inch needle. V19 drew 2mL in the syringe. Explained to R31 the procedure. V19 inserted the needle of the syringe into R31's right deltoid. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Activity of Daily Living (ADL) care to dependent residents. This deficiency affects two (R64 and R219) of seven residents in the sample of 39 reviewed for Providing ADL Care.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement physician orders of a low air loss mattress to a resident who is at high risk for developing skin impairment and has a history of pressure ulcers. This deficiency affects one (R64) of three residents in the sample of 39 reviewed for Wound/Pressure ulcer Prevention Management.

Inspectors wroteBased on interview and record review, the facility failed to conduct a complete and thorough investigation on a resident with an unknown injury. This affected one of three residents (R118) reviewed for safety in a sample of 39. Findings Include: On 9/26/2023 at 10:30am R118 was observed in bed with a leg immobilizer on her left leg. R118 is alert and oriented times three, R118 said that V42 (Certified Nursing Assistant/CNA) entered the room and said, 'I must hurry and get you out of the bed because you have an appointment.' V42 quickly assisted me to get dressed then V40 (Certified Nursing Assistant/Transporter) joined her, they both assisted me to stand holding me up by my arms and pants then pulled the wheelchair up close to the bed. They had me turn and sit in the chair but when I went to turn, my left foot was behind the wheel of the wheelchair, and they sat me down. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Administering Nebulizer Therapy policy when the nurse failed to obtain pre and post treatment lung sounds, pulse, and respiration rate. The nurse also failed to remain with the resident during the nebulizer treatment. This deficient practice affects 1 resident (R42) of 5 residents reviewed for medication administration in a total sample of 39 residents. Findings Include: On 9/27/23 at 10:08AM, medication administration observation conducted with V24 (Registered Nurse/RN). R42 has scheduled oral medication and nebulizer treatment medication. V24 instructed R42 to go in the room for Nebulizer treatment. V24 prepared the medication and placed the nebulizer mask on R42. V24 left R42's room and went to the nurse's station. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to refer and provide appropriate mental health/psychotherapy services to resident who has behavioral related disorders. This deficiency affects one (R127) of three residents in the sample of 39 reviewed for Behavioral Health Services program.

Inspectors wroteBased on observation, interview and record review, the facility failed to record the controlled drug medication administered to resident on controlled count sheet. This deficiency affects one of four medication carts reviewed for controlled substance record keeping.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor resident's refrigerator, dispose of expired food items, and maintain refrigerator temperature for one (R167) of three residents reviewed for food storage in the sample of 39.