The Home Place at Midway

Inspectors wroteBased on observation, interview, and review of the facility's documents, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations made on 02/24/2026, 02/25/2026, and 02/26/2026 revealed mold contamination in the ice machine. Observations on 02/25/2026 revealed Ezer (an aide) 3's and Ezer 4's hair nets did not cover the front section of their hair. This deficient practice had the potential to affect all 26 current residents.

Inspectors wroteBased on observation, interview, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The deficient practices had the potential to affect all residents with a census of 26. Observation and interviews on 02/26/2026 revealed hot water was stored at temperatures below the level needed to prevent growth of Legionella. Observation of the Hope and Faith House laundry rooms on 02/26/2026 revealed the aprons provided were made of cloth and would not protect staff clothing from splashes from contaminated linens. [...]

Inspectors wroteBased on observation, interview, and review of the facility's documents and policy, the facility failed to provide ongoing communication with residents about their rights to include not supporting and encouraging residents to organize and participate consistently in groups at the facility for 3 of 3 resident attendees present at the Resident Council meeting, Resident (R) R4, R5, and R25.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 out of 2 medication rooms observed, the Faith House Medication Room and the Hope House Medication Room. Observation on [DATE] of the Faith House Medication Room revealed three controlled substances belonging to Residents (R) 32 and R33, who no longer resided in the facility. Observation on [DATE] of the Hope House Medication Room revealed four controlled medication containers for R34 and two controlled medication containers for R35. Neither resident currently lived in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative of the transfer and the reasons for the move in writing for 1 of 1 resident investigated for hospitalizations, Resident (R) 28. R28 was transferred to the hospital on [DATE]; however, the facility failed to send a written notice of transfer to the resident's representative. Furthermore, the facility failed to provide evidence of sending the resident's representative a written copy of the bed hold notice for that hospitalization.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 22 current residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure health information was maintained in a private and confidential manner for 1 of 12 sampled residents, Resident (R) 16. On 04/08/2025, R16's Medication Administration Record (MAR) was observed unattended and exposed to public view.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 12 sampled residents, Resident (R) 28.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC)document, and review of the facility's policies, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 12 sampled residents, Resident (R) 2 and R16. Observation on 04/08/2025 revealed staff did not perform correct hand hygiene when providing care to R2. Observation on 04/08/2025 revealed staff did not correctly dispose of a gown worn during the care of R16, who was in Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety in two (2) of three (3) kitchens (Faith Cottage and Hope Cottage kitchens). The failed practices had the potential to affect all twenty-two (22) residents. Observations, on 05/09/2022, of the Faith Cottage kitchen, revealed a box of food stored on the floor; a dented can of food on the shelf for use; and, expired cans of food on the shelf for use. Observations, on 05/09/2022, of the Hope Cottage kitchen, revealed an opened package of raw beef stored next to an opened package of shredded cheese; and expired food items and dented cans of food available for use. [...]

Inspectors wroteBased on interview, review of manufacturer's directions for use, review of the Centers for Disease Control and Prevention (CDC) guidance, and the Occupational Safety and Health Administration (OSHA) requirements and the RB Sigma website, it was determined the facility failed to implement infection control procedures that included a respiratory protection program compliant with OSHA respiratory protection standards, including medical evaluations, training, and fit testing for the use of N95 respirators. This failed practice had the potential to affect all twenty-two (22) residents and occurred during the COVID-19 pandemic.

Inspectors wroteBased on interviews and review of the facility's policy, it was determined the facility failed to ensure the individual assigned the responsibilities of the Infection Preventionist (IP) had received specialized training in infection control and prevention. This had the potential to affect all twenty-two (22) residents residing in the facility.

Inspectors wroteBased on observation, interview, and review of the facility's procedure on mechanically altered diets, it was determined the facility failed to ensure pureed food was blended to a smooth consistency to meet the needs of residents who required a pureed diet, during one (1) of one (1) meal service observed. The failure had the potential to affect three (3) residents who required pureed diets out of twenty-two (22) facility residents.