Midwestern Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers to meet the needs of each resident for 1 of 1 (Resident #1) that received Enteral Feedings. LVN A failed to administered Resident #1's Enteral feeding for two hours after his feeding bag of nutrition ran out on 12/22/25. This deficient practice placed Resident #1 at risk for dehydration and insufficient caloric intake. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 15 residents (Residents #13 and #56) reviewed for resident rights. The facility failed to ensure Resident #25 and Resident #53 were served lunch in the dining room in a dignified manner on 7/08/2025. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. During an observation and interview on 8/26/25 at 12:05 PM Resident #25 and Resident #53 [JM1] were not served lunch with the rest of their table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, by failing to ensure: 1. The food fryer was left in an unsanitary condition, food fryer had not been cleaned after use, food crumbs dried to fryer baskets and inside fryer walls. 2. Cart with clean bowls and plates stored on it was not clean, food particles observed. 3. Floor behind stove, fryer and oven not swiped, food particles and trash found on floor. These failures could place residents at risk for decline in nutritional health status and foodborne illness. On 8/26/25 at 8:54 AM during the observation of dietary kitchen, fryer not clean, has food scrapes on baskets and fryer. Cart with clean bowls and plates stored on it was not clean, food particles observed. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement and maintain an effective training program for 1 of 16 existing staff (LPN E) whose training records were reviewed for multiple training topics, including the following: The facility failed to ensure LPN E was trained in Communication; QAPI; Resident Rights; Infection Control; Dementia; Abuse Neglect and Exploitation; Behavioral Health; HIV; Restraint Reduction; Falls; and Compliance and Ethics. These failures could place residents at risk of receiving care from incompetent/untrained staff.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 2 residents (Resident #8) reviewed for care plans.1. Resident #8 did not have a care plan developed to address his need for one-on-one in-room individual activity pursuits.2. Resident #8's care plan was not revised and updated with a care plan to address his bedbound status. This failure placed the resident at risk for social isolation, decreased awareness of his surroundings, and decreased feelings of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community, for 1 of 2 residents (Resident #8) reviewed for individual in-room one-on-one activity programming.1. Resident #8 was observed lying in his bed throughout the survey with no observed visitors or in-room activity programs offered to him from 8/26/25 to 8/28/25.2. Resident #8 did not have an individual in-room activities program developed to meet his interests. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 3 residents (Resident #34) reviewed for pressure injuries. The facility failed to ensure Resident #34's wheelchair had a pressure reduction cushion on 8/28/2025. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Record review of Resident #34 's Face Sheet revealed Resident #34 was a -year-old male admitted on with diagnoses of hypertension (high blood-pressure), hemiplegia and hemiparesis (loss of strength or paralysis), cerebral infarction (stroke), muscle wasting (muscle loss). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, for 1 (Resident #1) of 16 residents reviewed. As a result of the failure to implement the facility policy, the resident was not free from abuse, staff did not report the abuse, residents were not protected from further abuse, and the facility administration was unaware of the verbal abuse and police intervention on 05/04/2025 between LVN B and Resident #1 until surveyor intervention on 05/18/2025 This failure resulted in the identification of Immediate Jeopardy (IJ) on 6/04/25 at 2:09 pm. While the immediacy was removed on 6/06/25 at 1:02 pm, the facility remained out of compliance at scope of pattern and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report all allegations of abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 (Resident #1) of 16 residents reviewed. CNA B, CNA C, CNA E, and CNA D failed to report verbal abuse of Resident #1 to the administrator or the DON. There was police intervention between the staff and resident. As a result of not reporting, the administrative staff were not aware until surveyor intervention. Include the incident happened on 5/4/25 and administration were not aware of the verbal abuse until 5/18/25. This failure resulted in the identification of Immediate Jeopardy (IJ) on 6/04/25 at 2:09 pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the residents free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 16 residents reviewed. The facility failed to prevent verbal abuse to Resident #1 by LVN B. This failure resulted in the identification of Immediate Jeopardy (IJ) on 6/04/25 at 2:09 pm. While the immediacy was removed on 6/06/25 at 1:02 pm, the facility remained out of compliance at scope of pattern and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place the residents at risk of serious emotional, psychological, and physical anguish.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. Appliance surfaces were soiled with dried food, grease and burned food. 2. Bulk storage container lids were soiled with food particles and dust. 3. Opened food item packages in the refrigerator, freezer, and dry food storage room were not placed in sealed containers, were not labeled with the contents, and were not dated when opened. 4. Expired milk was stored on the shelves in the refrigerator. 5. Cartons of expired prune juice was stored on a shelf in the dry food storage room. 6. Cooking utensils and pans were stored with their sanitized surfaces exposed to contaminants in the air. 7. [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon the grievances of the resident group concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response for 2 of 3 Resident Council Meetings, in that: 1. Concerns voiced during the monthly Resident Council Meetings were not addressed following meetings held on 4/17/2024 and 5/20/2024. 2. The Resident Council members were not notified regarding facility action taken to address and resolve concerns voiced in prior Resident Council Meetings during the next monthly meetings held on 5/20/2024 and 6/04/2024. 3. The follow-up to Resident Council concerns and discussion of old business were not documented as reviewed, read, resolved, or unresolved on the Resident Council Minutes form dated 5/20/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for 2 of 2 resident rooms reviewed for homelike environment. (Resident #3 and Resident #2) The facility failed to properly clean the sheets for Resident #3. The facility failed to properly clean the walls, privacy curtain, and floors in Resident #2's room. This deficient practice could place residents at risk of an unclean and homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to have assessments that accurately reflect the status of 1 of 3 residents (Resident #1) reviewed for resident assessments. Resident #1's Annual MDS did not reflect his current behavioral state. This failure could place residents at risk of a decreased quality of care and not having their individualized needs met or communicated accurately to staff. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which included measurable objectives and time frames to meet residents' mental and psychosocial needs, for one (Resident #1) of three residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #1's physical, verbal, and sexual aggressive behaviors towards staff, visual function, risk for falls, risk for pressure ulcers, antianxiety medications, and 1:1 staffing. This failure could place residents at risk for their medical, physical, and psychosocial needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for one of two residents (Resident #3) reviewed for activities of daily living. The facility failed to provide Resident #3 with assistance with ADLs as care planned. This failure placed residents at risk of not maintaining good hygiene and assistance with ADL's.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured on 2 of 2 medication carts reviewed for pharmacy services. The facility did not ensure medications carts were secured and locked. This failure could place the residents at risk of a drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident were complete in accordance with accepted professional standards and practices for 1 of 15 residents (Resident #1) whose clinical records were reviewed for accuracy. The facility failed to ensure Resident #1's clinical record had a physician's orders entered for the 1 on 1 observations, scheduled documentation of the observations, missing signatures of who wrote the notes on the 1 on 1 observations on the paper documentation. This failure could place residents at risk for inaccurate or incomplete clinical records.

Inspectors wroteBased on observation and interview the facility failed to ensure that the daily nurse staffing was posted and readily accessible to residents and visitors as required for 1 of 2 days reviewed for nurse staffing The facility failed to update the daily staffing information posting from 10/27/2023 to 11/01/2023. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu for all residents reviewed for food preferences. The facility failed to provide an acceptable substitute for dessert at lunch when they served whipped cream with graham cracker crumbs instead of the scheduled Key Lime pie. This failure could place residents at risk of feeling that their preferences are not being met.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a comprehensive assessment was completed within 14 days after a significant change in the physical or mental condition for 1 of 3 residents (Residents #8) whose records were reviewed for assessments. The facility failed to capture a comprehensive MDS assessment after Resident #8 returned to the facility from the hospital and had a significant decline. This failure placed could place residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments.

Inspectors wroteBased on interviews and record review the facility failed to refer 1 of 4 residents whose PASARR evaluations were reviewed (Resident #54) who had newly evident mental disorders in that: The facility failed to refer Resident #54 for PASARR review following new mental illness diagnoses. This deficient practice could affect 4 residents who had qualifying diagnoses with a negative PASARR Level 1 evaluation.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 6 residents (Resident #65) whose records were reviewed for assessments and care plans, as well as having an IDT team present at the care conference. The facility failed to ensure Resident #65 had a comprehensive care plan developed and updated within 7 days following the completion of the admission comprehensive assessment. This failure could place residents at risk of not have having their care plans completed accurately and timely.