Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Midland during CMS and state inspections, most recent first.
A resident with vascular dementia and moderate cognitive impairment had her face sheet and personal information disclosed to a hospice provider by the DON without authorization from the resident’s guardian. The guardian later received a voicemail from the hospice company stating they already had the resident’s information and offering services, even though the guardian had not shared any records. The Corporate Nurse reported that the DON gave the hospice provider the resident’s face sheet when the provider was in the building and acknowledged this should not have occurred, contrary to facility policies prohibiting unauthorized release of resident information.
The facility failed to maintain an effective pest control program, resulting in ongoing mice activity in resident care areas. A cognitively intact male resident with depressive disorder, anxiety, and muscle weakness reported repeatedly seeing mice in his room, losing food to them, and observing no real improvement despite telling staff. Staff, including the HD, a MA, and an RN, acknowledged seeing mice running in hallways and on units, as well as mouse feces under resident beds, and confirmed the issue had been reported to maintenance. The Administrator and Corporate Maintenance Director admitted there was an ongoing mice problem and that no pest control policy existed. Surveyor observation found multiple rat droppings in a resident’s nightstand drawer and a dead mouse on the resident’s porch, demonstrating that the environment was not free of pests.
Surveyors found unsanitary and unsafe conditions throughout the facility, including trash and food debris on floors, overflowing trashcans, broken window blinds, and damaged floor tiles in resident rooms and common areas. The administrator attributed the issues to a late floor tech and acknowledged that staff are responsible for cleaning, but could not provide a policy on maintaining a homelike environment.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
The facility did not ensure food was prepared safely and attractively, as a Dietary Aide was observed not following puree recipes, not measuring ingredients, and lacking training on proper food preparation. Multiple residents reported dissatisfaction with the food's taste and temperature, and observations showed unappetizing meals. The Dietary Manager confirmed staff were untrained in pureed food preparation and that no specific policy on food palatability existed.
Surveyors found that three resident smoking areas were not adequately cleaned or maintained, with high grass, overflowing trash, scattered litter, and cigarette butts present throughout. Maintenance logs showed the last cleaning occurred several days prior, and mowing was delayed due to contractor issues. The areas also contained items such as cat food and bedding covered in debris.
Surveyors observed that two dumpsters had open lids and trash, including a toilet and wooden items, was found outside the dumpsters. The area was not kept free of garbage and debris, and no policy on garbage and refuse disposal was provided during the survey. The Administrator stated that the expectation was for dumpster lids to remain closed and the area to be clean.
Staff failed to maintain resident dignity by instructing a resident with cognitive impairment to urinate in her brief instead of assisting her to the bathroom, and multiple residents reported that staff frequently used personal cell phones during direct care, including wound care and medication administration. Facility leadership confirmed these actions were not consistent with policy, which requires prompt toileting assistance and prohibits personal cell phone use during care.
Surveyors found that staff failed to document the administration of controlled medications immediately after giving them, resulting in discrepancies between medication records and actual pill counts for several residents with conditions such as epilepsy, chronic pain, and anxiety. The medication aide typically signed out controlled substances during shift changes rather than at the time of administration, contrary to facility policy and expectations stated by the DON and Administrator.
A resident who was assessed as safe to smoke independently was found with a lighter left unattended on his bedside table, in violation of facility policy and his care plan, which required all smoking materials to be stored by staff. This failure to secure incendiary devices resulted in the environment not being as free from accident hazards as possible.
A resident with multiple chronic conditions was taken to the emergency room after being locked out of the facility and seeking help at a nearby restaurant. Although an LVN performed an assessment upon the resident's return, no documentation of the emergency room visit, the circumstances, or the assessment was entered into the medical record, as the LVN was instructed not to document by a Regional Compliance RN. Facility staff and leadership confirmed that documentation was expected but not completed, resulting in incomplete medical records.
A resident with severe cognitive impairment and a known risk for elopement was able to leave a secured unit by following a contract worker out during construction, exiting the facility undetected, and was later found by police nearly a mile away. The incident was marked by inadequate supervision at the secured door, lack of staff assignment to monitor exits during increased risk, and missing documentation and incident reporting, leading to an Immediate Jeopardy finding.
A resident with severe cognitive impairment and a history of elopement did not have their care plan updated after new elopement incidents. The existing care plan addressed general wandering but lacked specific, measurable interventions following actual elopements, and no incident report was completed. Staff interviews revealed a lack of awareness and follow-through in updating the care plan as required by facility policy.
A resident with a history of schizophrenia and diabetes, at risk for pressure ulcers, did not receive weekly skin assessments from mid-July to late September due to frequent absences on scheduled assessment days. On one occasion, the resident was observed with pitting edema and seeping fluid on his legs, but no treatment orders were in place. The facility's policy requiring weekly skin assessments was not followed, resulting in untreated skin issues.
The facility failed to maintain a clean and safe environment, with surveyors observing dirt and food crumbs along the walls in six hallways, the dining room, and the kitchen. The Administrator acknowledged the issue, citing new housekeeping staff and the potential risks of unclean floors. The facility's policy requires daily cleaning of floors.
A facility failed to maintain accurate records for a resident who frequently left the premises. Despite being cognitively intact and having permission to leave, the resident did not consistently sign in or out, leading to incomplete documentation. Interviews revealed that while staff reminded residents to sign in and out, the procedure was not always followed, resulting in a deficiency in maintaining clinical records.
A resident requiring total assistance for toileting was subject to improper infection control practices by CNA A and Hospitality Aid B, who failed to perform hand hygiene between glove changes during incontinence care. Despite recent training, the staff members admitted to forgetting the procedure due to nervousness. The DON confirmed that this was against facility policy, which mandates hand hygiene after every glove change.
The facility failed to implement comprehensive care plans with enhanced barrier precautions (EBP) for three residents, leading to increased infection risk. A resident with pressure ulcers and a catheter lacked EBP in his care plan. Another resident with severe cognitive impairment and a feeding tube also lacked EBP interventions. Similarly, a third resident's care plan did not include EBP for his catheter and pressure injury. The MDS Coordinator admitted the oversight, highlighting a lack of understanding of EBP's importance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and indwelling medical devices, as evidenced by the lack of documentation, signage, and PPE availability. Observations and staff interviews revealed inconsistencies in understanding and applying EBP protocols, with some staff unaware of its existence. This deficiency increased the risk of cross-contamination and infection spread among residents.
A facility failed to complete post-dialysis assessments for a resident with end-stage renal disease, despite having a care plan in place. The resident, who had severe cognitive impairment, did not receive necessary post-dialysis evaluations, including vital signs and AV shunt checks. Interviews with staff revealed a lack of follow-up and documentation, and no dialysis policy was provided.
The facility failed to post required contact information for State agencies and advocacy groups in an accessible manner for residents and their representatives. The ADON and DON were unable to locate the postings, which had been removed during repainting and not replaced. The Administrator was aware of the requirement but did not know why the postings were missing, and a temporary 1-800 number was posted instead.
The facility failed to develop and implement comprehensive care plans for five residents, leading to deficiencies in catheter care, PEG tube management, unplanned weight loss, and psychotropic medication use. The CRC and DON acknowledged the oversight and inconsistencies in care plan documentation.
The facility failed to ensure that secure unit exit doors had alarms to alert staff when residents went outside to the patios. Observations and interviews revealed that staff monitored residents by physically checking the patios, and the facility lacked a specific policy regarding secured doors in the secure unit.
The facility failed to maintain a clean kitchen and ensure proper food storage, preparation, and distribution. Observations revealed pooled water, grime buildup, and improperly labeled and stored food items. Interviews confirmed awareness of the issues, with ongoing efforts to address them.
The facility failed to maintain an effective pest control program, resulting in a rodent infestation. Despite weekly treatments by a new pest control vendor, residents continued to feed the mice, complicating eradication efforts. A dead rat was found in a supply closet, and the issue persisted despite multiple discussions with residents about the health risks.
The facility failed to ensure the dignity and privacy of two residents by not covering their urinary catheter drainage bags with privacy bags. Observations revealed that the urine content of the bags was visible to others, and neither resident had a comprehensive care plan for their urinary catheters. Staff interviews confirmed that the facility's policy required privacy bags, but they often fell off or were removed by residents.
The facility failed to ensure the accurate administering of drugs by having two expired insulin pens in a medication cart. LVN A did not notice the expired pens, and the ADON confirmed it was each nurse's responsibility to check and dispose of expired medications. The Administrator acknowledged that no specific person was assigned to check for expired medications, leading to this oversight.
The facility failed to store drugs and biologicals in locked compartments, as the medication cart for halls A, B, and C was found unlocked and unattended. LVN A admitted to forgetting to lock the cart, which contained several medications. The ADON and Administrator confirmed the expectation for carts to be locked when not in use.
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as grey water and soiled toilet tissue were observed streaming from a drain clean out and pooling in the parking lot. Despite efforts to address the issue, the problem persisted, posing a hazard to residents, staff, and the public.
Unauthorized Disclosure of Resident Information to Hospice Provider
Penalty
Summary
The facility failed to maintain the confidentiality of a resident’s personal and medical information when the DON provided the resident’s face sheet to a hospice provider without appropriate authorization. The resident was an older female with vascular dementia, mood disturbance, and anxiety, with a quarterly MDS showing a BIMS score of 11, indicating moderate cognitive impairment. The resident had an initial admission date of 10/22/24, and a face sheet dated 4/23/26 was part of her record. The resident’s guardian, who became guardian on 3/23/26, reported receiving a voicemail from a hospice company stating they had all of the resident’s information and offering hospice services, despite the guardian never having provided this information or consent for its release. During an interview, the Corporate Nurse reported that the DON had told her by phone that a hospice provider was in the building, came by her office, and that the DON gave the hospice company the resident’s face sheet. The Corporate Nurse acknowledged that this should not have been done and believed it was a HIPAA violation. The facility’s written policies on Confidentiality of Information and Resident Rights required that all resident information be treated confidentially, that resident records be safeguarded, and that unauthorized release, access, or disclosure of resident information was prohibited, with all such matters to be handled in accordance with privacy laws and directed to the HIPAA compliance officer. Despite these policies, the resident’s personal and medical information was disclosed to the hospice provider without authorization from the guardian.
Failure to Maintain Effective Pest Control Resulting in Ongoing Mice Infestation
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program to keep the environment free of mice and rodents, including in a cognitively intact male resident’s room. The resident, with diagnoses including depressive disorder, anxiety, and muscle weakness, reported that his only complaint about the facility was the mice. He stated he had informed multiple staff members, was told the issue was being worked on, but did not see improvement. He described seeing two mice in his room the previous night, noted that mice sometimes came out during the day, and reported losing two pieces of food/bread after finding partially opened bags with nibble marks and bread that had been eaten. Staff interviews and observations further demonstrated ongoing mouse activity throughout the facility. The Housekeeping Director acknowledged there had been mice, that it used to be worse, and that CNAs on one hall had reported seeing mice; she stated she had been working with pest control and maintenance and believed the situation had improved in the last three weeks. A medication aide reported seeing two mice running up and down another hall about a week prior and felt not much had been done. An RN stated she had seen mice running on the unit and mouse feces under different residents’ beds, and that she had notified the Maintenance Director. The Administrator and Corporate Maintenance Director both acknowledged an ongoing mice issue, with the Corporate Maintenance Director stating there was no pest control policy. During observation, surveyors found multiple rat droppings in a resident room nightstand drawer and a dead mouse on the resident’s porch, confirming the facility was not free of mice.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, as evidenced by multiple observations of unclean and poorly maintained areas. On the date of the survey, Hall B was found with floors covered in trash, food particles, and candy wrappers between the handrail and wall. Resident rooms in Hall B had brown dry stains on the floor, overflowing trashcans, trash under beds, broken window blinds, and broken floor tiles. The dining room floor was also observed to have trash, food, and cups scattered throughout, despite breakfast having been served hours earlier. Similar unsanitary conditions were noted in Hall A, with floors covered in trash and food particles. Interviews revealed that the floor technician was late on the day of the observation, which contributed to the lack of cleanliness. The administrator acknowledged that staff are responsible for emptying trashcans and cleaning floors as needed, and stated that all staff had been in-serviced regarding their responsibility to maintain cleanliness. However, the administrator was unable to provide a policy on maintaining a homelike environment during the exit conference. No specific residents were identified as being directly affected in the report, and no medical history or conditions were mentioned.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific residents, staff, or events are provided in the report.
Failure to Prepare Palatable and Safe Food Due to Lack of Training and Recipe Use
Penalty
Summary
The facility failed to ensure that food was prepared in a safe, palatable, and attractive manner, particularly in the preparation of pureed food items. Observations revealed that a Dietary Aide (DA) did not follow puree recipes, did not measure liquids or thickeners, and was not trained on the correct procedures for preparing pureed foods. The DA relied on personal judgment to determine the amount and type of liquid to add, and was unaware of the existence of recipes or the importance of consistency in food texture, which could affect resident safety. The DA also did not take temperatures of the pureed foods before serving. The Dietary Manager (DM) confirmed that none of the Dietary Aides had received training on preparing purees and acknowledged that staff often filled in for positions without proper training. Multiple residents interviewed expressed dissatisfaction with the quality, temperature, and taste of the food, describing it as unappetizing and not good. Observations of a lunch test tray showed the food was unappetizing in appearance, with dried-out meat and overly peppered gravy, and the meat was difficult to cut. The Registered Dietician indicated that the DM was instructed to provide menus and recipes to staff, but there was no evidence that this had been done. The DM also stated there was no specific policy related to food palatability. Record review showed no significant weight loss among residents at the time of the survey.
Failure to Maintain Clean and Sanitary Resident Smoking Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in three designated resident smoking areas. Observations revealed that in smoking area 1, the grass and weeds were approximately 24 inches high, and the area was littered with trash such as used gloves, paper, cans, food wrappers, and numerous cigarette butts. This area is shared by the men's locked units E and F. In smoking area 2, located in the women's locked unit from hall C, there was scattered litter including paper, cans, cups, food wrappers, and cigarette butts, with the trash can overflowing and weeds/grass up to 1 foot tall. Smoking area 3, shared by halls A, B, and D, was observed to have trash, used gloves, paper, cans, food wrappers, and cigarette butts throughout. Additionally, this area contained a cat food bowl, a bag of cat food, and two cat houses, one of which had a blanket covered in cigarette butts, grass, and trash. Interviews and record reviews indicated that maintenance staff are responsible for cleaning the outside grounds, including smoking areas, every Monday, Wednesday, and Friday, while mowing is performed by a contractor who does not address the smoking areas unless specifically requested. The most recent maintenance log check-off for smoking area cleaning was dated several days prior to the observations. The administrator confirmed that mowing was not completed as scheduled due to mechanical issues with the contractor, and that the facility's expectation is to maintain a clean and sanitary environment. The facility's policy for a clean sanitary environment was not provided at the time of exit.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse for 2 out of 3 dumpsters, as observed during a survey. Specifically, the lids on two dumpsters were left open despite the dumpsters not being full, and trash, including a trash bag, a toilet, and wooden items, was found outside the dumpsters. The area surrounding the dumpsters was not free of garbage and debris. During an interview, the Administrator confirmed that the expectation was for dumpster lids to remain closed and the area to be free of trash or debris. The maintenance director was reported to conduct rounds outside the facility three times a week. No policy on garbage and refuse disposal was provided by the time of the survey exit. No specific residents or staff were directly involved in the observed deficiency, and no medical history or condition of residents was mentioned in relation to this event.
Failure to Maintain Resident Dignity and Prohibit Personal Cell Phone Use During Care
Penalty
Summary
Staff failed to treat residents with respect and dignity, as evidenced by multiple observations and interviews. One resident with severe cognitive impairment and incontinence was told by a CNA to urinate in her brief instead of being assisted to the bathroom, despite her request and care plan interventions that included prompted toileting and peri-care. The resident was observed crying out for help, and the CNA dismissed her request, instructing her to use her brief because it was dry. Additionally, several residents reported that staff frequently used their cell phones while providing direct care, including during wound care and medication administration. Residents described staff watching television shows or texting friends on their phones, which made them feel uncomfortable and neglected. One resident noted that a staff member did not change gloves after using their phone during wound care. Observations confirmed that a nurse was scrolling on social media while sitting next to a resident in the dining room. Interviews with facility leadership confirmed that personal cell phone use was not permitted during resident care, except for specific business-related reasons. Both the DON and Administrator acknowledged that telling residents to urinate in their briefs was not acceptable and not in line with facility policy. Facility policies reviewed emphasized the importance of treating residents with dignity and promptly responding to toileting needs, as well as prohibiting personal cell phone use while working on the floor or in resident rooms.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure that drug records were accurately maintained and that an account of all controlled drugs was kept for multiple residents. During an inspection of a medication cart, discrepancies were found between the number of controlled medication pills documented on individual medication records and the actual number of pills present in the blister packs for eight residents. These discrepancies were observed for various controlled substances, including phenytoin, acetaminophen-codeine, clonazepam, pregabalin, alprazolam, tramadol, and lorazepam. The medication aide responsible for administering these medications did not document the administration of controlled substances on the individual controlled medication records immediately after giving the medication. Instead, the aide reported typically signing out the controlled medication sheets during the shift count with oncoming staff, rather than at the time of administration. This practice resulted in mismatches between the recorded and actual pill counts for several residents with diagnoses such as epilepsy, chronic pain syndrome, anxiety disorder, fibromyalgia, and joint pain. Interviews with facility leadership, including the DON and the Administrator, confirmed that the expectation was for staff to sign out controlled medications immediately after administration, as outlined in the facility's policy. The policy requires that controlled substance inventory sheets be accurately maintained and that a log is used to track controlled substances from delivery to disposition, in accordance with federal and state regulations. The failure to follow these procedures led to the observed discrepancies in medication records.
Failure to Secure Smoking Materials for Independent Smoker
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and that adequate supervision was provided to prevent accidents for a resident who smoked independently. Observation revealed that a lighter was left unattended on the resident's bedside table, contrary to the facility's policy and the resident's care plan, which required all lighters and smoking materials to be kept with facility staff for safety. The resident was cognitively intact and assessed as safe to smoke unsupervised, but the care plan specifically stated that smoking materials must be returned to the nurse's station after use and not kept on the resident's person. The facility's smoking policy required that incendiary devices and smoking materials be stored by staff and not be in the possession of residents. Despite this, the resident was found with a lighter in his room, and the DON acknowledged the oversight, noting that the resident often went out on pass alone and was considered an independent smoker. The failure to follow established procedures for the storage of smoking materials created a situation where the resident environment was not as free from accident hazards as possible.
Failure to Document Resident's Emergency Room Visit and Return Assessment
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident who was sent to the emergency room. The resident, an older adult with multiple diagnoses including diabetes, atrial fibrillation, COPD, and bipolar disorder, left the facility and was taken to the emergency room after being locked out and seeking help at a nearby restaurant. Upon her return, a head-to-toe assessment was performed by an LVN, but no documentation of the emergency room visit, the circumstances leading to it, or the assessment upon return was entered into the medical record. Interviews with facility staff revealed that the LVN did not document the assessment or complete an incident report because she was instructed not to by the Regional Compliance RN. The DON disagreed with this directive and believed documentation should have occurred. Other nursing staff, the administrator, nurse practitioners, and the medical director all stated that documentation of the emergency room visit and the resident's return assessment was expected and should have been completed. The Regional Compliance RN later stated that documentation was required and could not recall instructing staff otherwise. A review of facility policies indicated that accidents or incidents involving residents should be investigated and reported, and that nurses are required to complete descriptive documentation based on resident assessments. However, the facility did not have a specific policy addressing documentation requirements for residents returning from the hospital or emergency room. The lack of documentation in this case resulted in incomplete medical records for the resident involved.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
A deficiency occurred when a male resident with severe cognitive impairment and a high risk for elopement, as documented in his care plan and elopement assessment, was able to leave the secured unit and exit the facility without staff detection. The resident, who had dementia with behavioral disturbance and a history of wandering, followed a contract worker out of the secured unit during a period of construction and subsequently exited the building. Staff interviews and record reviews revealed that the door to the secured unit was not properly monitored, and there was no staff member specifically assigned to watch the door during the construction activities, despite the increased risk. The incident was further compounded by a lack of proper documentation and communication among staff. There was no incident or accident report for the elopement in the electronic record, and nurse's notes for the day of the incident were missing. Staff interviews indicated confusion about the timeline and responsibilities, with some staff unaware of the resident's absence until after he had left the facility. The Director of Nursing (DON) and Administrator acknowledged failures in documentation and investigation, including not taking statements from all relevant staff and not maintaining head count forms as required by facility policy. The facility's investigation confirmed that the resident was missing for approximately two hours before being found by police nearly a mile away. The lack of supervision at the secured unit door, inadequate staff training or understanding regarding door security during construction, and insufficient documentation and follow-up all contributed to the resident's ability to elope. These failures resulted in the identification of an Immediate Jeopardy situation due to the potential for serious harm.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of dementia, behavioral disturbances, and high elopement risk. Despite the resident's documented severe cognitive impairment and previous elopement incidents, the care plan was not updated to address new elopement events. The care plan in place focused on general wandering and safety within the secured unit but did not include specific, measurable objectives or interventions following the resident's actual elopements. There was also no incident or accident report completed for a documented elopement, and the care plan was not revised to reflect this significant event. Interviews with facility staff, including the Administrator, DON, Regional RN Consultant, and MDS Coordinator, revealed a lack of awareness and follow-through regarding the need to update the care plan after elopement incidents. The MDS Coordinator acknowledged that care plans should be updated after such events but did not do so, believing the existing at-risk care plan was sufficient. The facility's policy required care plans to be revised after significant changes in a resident's condition, but this was not followed in the case of the resident's elopement.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to conduct weekly skin assessments for a resident from mid-July to late September, as required by their policy. The resident, who was cognitively intact and had a history of paranoid schizophrenia and Type II Diabetes Mellitus with Diabetic Peripheral Angiopathy, was at risk for developing pressure ulcers. Despite this risk, the resident's skin was not assessed weekly because he often left the facility on his scheduled assessment day. This oversight was confirmed during an interview with the wound care nurse, who admitted that the resident's skin was not assessed upon his return from being out of the facility. On September 23, the resident was observed with pitting edema and seeping serosanguinous fluid on his lower legs, yet there were no physician orders for treatment or assessment of this condition. The Director of Nursing acknowledged that the resident should have been evaluated upon returning to the facility if absent on the scheduled assessment day. The facility's policy on skin management, which mandates documentation of skin assessments every seven days, was not adhered to, leading to a lack of treatment for the resident's skin issues.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents, staff, and the public, as observed in six hallways, the dining room, and the kitchen. On two separate occasions, surveyors noted dirt and food crumbs along the walls at the baseboards in these areas. The observations were made on 09/19/2024 and 09/24/2024, indicating a persistent issue with cleanliness in the facility. Interviews with the Administrator revealed that there was an expectation for the floors to be cleaned, and it was acknowledged that the facility had a new housekeeping director and staff who were working on improving the situation. The Administrator also recognized the potential negative outcomes of not maintaining clean floors, such as fall hazards, infection control issues, and attracting pests. A review of the facility's policy on floor maintenance, last revised in December 2009, stated that all floors should be mopped, cleaned, or vacuumed daily according to established procedures.
Failure to Maintain Accurate Resident Sign-In/Out Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who was reviewed for signing themselves in and out of the facility. The resident, who was diagnosed with Paranoid Schizophrenia and Type II Diabetes Mellitus with Diabetic Peripheral Angiopathy, was cognitively intact and had a physician's order allowing them to go out on therapeutic pass with medications. However, the resident did not consistently sign out or back into the facility on multiple occasions in August and September 2024. Interviews with the facility's Medical Director and Administrator revealed that the resident was competent and frequently left the facility on their own accord. The Administrator acknowledged that it was the resident's responsibility to sign in and out, with staff reminding them to do so. Despite this, the resident admitted to not always signing out or back in. The facility's Admission Agreement emphasized the importance of informing staff and signing in and out when leaving and returning to the premises, but this procedure was not consistently followed, leading to incomplete and inaccurate documentation of the resident's whereabouts.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and Hospitality Aid B during incontinence care for a resident. The resident, a male with a history of cerebral infarction and requiring total assistance for toileting, was observed receiving care where the staff members did not perform hand hygiene between glove changes. This oversight occurred despite the staff having recently passed a competency check and completed an in-service on hand hygiene. During the care, CNA A and Hospitality Aid B removed the resident's soiled brief, cleaned the resident, and changed gloves without performing hand hygiene in between. Both staff members acknowledged their mistake, attributing it to nervousness. The Director of Nursing confirmed that the facility's policy required hand hygiene after every glove change and recognized that the failure to adhere to this policy could lead to infection.
Failure to Implement Comprehensive Care Plans with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, which included measurable objectives and time frames to meet their highest practicable physical, mental, and psychosocial well-being. Resident #2 did not have a care plan addressing enhanced barrier precautions (EBP) for his pressure ulcers or catheter. His care plan focused on pressure ulcer management but lacked specific interventions for EBP, which are crucial for preventing infections. Resident #3 also lacked a care plan addressing EBP for his catheter, feeding tube, or pressure ulcer. Despite having severe cognitive impairment and being dependent on a feeding tube for nutrition, his care plan did not include EBP interventions. The absence of these precautions increased the risk of infection and cross-contamination, as noted by the MDS Coordinator during the interview. Similarly, Resident #4's care plan did not include EBP for his catheter and pressure injury. Although his care plan addressed pressure injury and catheter management, it failed to incorporate EBP, which is essential for infection prevention. The MDS Coordinator acknowledged the oversight, stating that EBP should have been care planned for residents at particular risk for infection, but it was not done due to a lack of understanding of its importance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in implementing Enhanced Barrier Precautions (EBP) for three residents with chronic wounds and indwelling medical devices. Resident #2, a cognitively intact male with multiple pressure ulcers and an indwelling catheter, did not have EBP measures documented in his care plan or orders. Observations revealed no signage or PPE availability indicating EBP status, increasing the risk of cross-contamination and infection spread. Resident #3, with severe cognitive impairment, a feeding tube, and a stage III pressure ulcer, also lacked EBP documentation in his care plan. Observations showed no EBP signage or PPE at his bedside, and staff interviews indicated a lack of awareness and training on EBP protocols. Similarly, Resident #4, with severe cognitive impairment, an indwelling catheter, and a stage III pressure ulcer, had no EBP measures documented or implemented, as evidenced by the absence of signage and PPE. Interviews with facility staff, including the DON, ADON, and various nursing staff, revealed inconsistencies in understanding and implementing EBP. The ADON, responsible for infection control, admitted to not having posted necessary signage and acknowledged gaps in staff education. Staff members expressed confusion and lack of training regarding EBP, with some unaware of its existence or purpose, highlighting a systemic failure in the facility's infection control practices.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide adequate post-dialysis care for a resident who required dialysis services. The resident, a male with severe cognitive impairment and end-stage renal disease, was admitted with a history of kidney failure and was dependent on dialysis. Despite having a care plan that included monitoring for symptoms of kidney failure and ensuring the resident attended dialysis sessions, the facility did not complete post-dialysis assessments on multiple occasions. These assessments were crucial for checking vital signs and the condition of the resident's AV shunt, which were not documented in the resident's records. Interviews with facility staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed a lack of follow-up on post-dialysis assessments. The DON acknowledged that the resident often refused dialysis sessions and that the dialysis information was kept in a notebook before being entered into the electronic medical record. The Administrator confirmed that while pre-dialysis assessments were completed, post-dialysis assessments were consistently missing. The ADON admitted that they were responsible for ensuring chart documentation was complete but were not present when the resident returned from dialysis. The absence of a dialysis policy and the failure to complete post-dialysis assessments could lead to unrecognized changes in the resident's condition. The ADON highlighted the importance of these assessments in identifying potential issues such as infection or malfunction of the dialysis access site. Despite the facility's acknowledgment of the deficiency, no policy on dialysis was provided to the surveyor.
Failure to Post Required State Agency Contact Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups in a manner accessible and understandable to residents and their representatives. This list should include the State Survey Agency, the State licensure office, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. During an observation and interview, the Assistant Director of Nursing (ADON) was unable to locate the required postings in any of the facility's public areas, including the dining room and lobby. The ADON admitted to not knowing where the information was posted and had to search unsuccessfully for it. Further interviews revealed that the Director of Nursing (DON) was also unaware of the current location of the postings, acknowledging that they had been removed during a repainting of the facility and had not been replaced. The Administrator confirmed awareness of the requirement for these postings but did not know why they were missing. The Administrator mentioned that a new poster with the necessary information was supposed to be provided by the Corporate President but had not yet arrived. In the meantime, a temporary 1-800 number was posted. The facility's policy on Resident Rights and Abuse emphasizes the importance of maintaining these postings to ensure residents can communicate with outside agencies regarding any concerns.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, leading to deficiencies in their care. Resident #33, a male with congestive heart failure, type 2 diabetes, and prostate hypertrophy, did not have a care plan in place for his urinary catheter despite physician orders for Foley catheter care. Similarly, Resident #72, who also had an indwelling catheter, lacked a care plan addressing his catheter care needs. Resident #37, a female with severe cognitive impairment and dysphagia, did not have a care plan for her PEG tube, despite multiple physician orders detailing the care required for her feeding tube. Additionally, Resident #79, who experienced significant unplanned weight loss, did not have a care plan addressing her nutritional needs and weight management. This resident had a severe cognitive impairment and required moderate assistance with most ADLs. Resident #137, a female with psychosis and generalized anxiety disorder, was receiving psychotropic medications without a corresponding care plan. The facility's CRC acknowledged the oversight and stated that care plans were mostly left to him, leading to missed updates. The DON confirmed that care plans should automatically include critical aspects like catheters and psychotropic medications but admitted that the facility had inconsistencies in care plan documentation and weight management.
Failure to Ensure Secure Unit Exit Doors Had Alarms
Penalty
Summary
The facility failed to ensure that the secure units' exit doors at the end of each hall had alarms to indicate and alert staff that residents were going outside to the secure unit patios. This deficiency was observed from 04/09/24 through 04/11/24, during which several residents were seen going in and out of the secure unit patios without proper supervision. Staff were observed monitoring residents inside the units but not necessarily those outside on the patios. Interviews with multiple CNAs revealed that they were unaware of any alarms on the exit doors and monitored residents by physically checking the patios periodically. The Maintenance Supervisor, who had been with the facility for almost two years, also confirmed the absence of alarms and was unaware that the secure unit doors required them. The Administrator acknowledged the lack of alarms and stated that staff were supposed to monitor residents in the patios, but did not consider the need for alarms as the patios were secure areas. During observations, it was noted that the male secure unit's exterior doors did not have an alarm to alert staff when residents went outside, and the exterior door on E hall did not have a latch to close properly. Interviews with CNAs indicated that they relied on visual checks and physical rounds to monitor residents in the patios. None of the CNAs reported any incidents of residents falling outside, but they all confirmed the absence of door alarms. The facility did not provide or have a specific policy regarding secured doors in the secure unit, which contributed to the lack of adequate supervision and potential accident hazards for the residents.
Failure to Maintain Clean Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean kitchen and ensure proper food storage, preparation, and distribution in accordance with professional standards. Observations revealed pooled water in front of the three-compartment sink, an opened and spilling bag of dry gravy in the dry pantry, brown grime along the walls and under storage shelves, and a buildup of grime on equipment. Additionally, stainless steel freezer doors, handles, rolling carts, and kitchen floors were visibly dirty, and the wall behind the dishwasher was covered in black grime. The freezer contained two opened, unlabeled, and undated bags of frozen white nuggets. Interviews with the Director of Food and Nutrition Services (DM) and the Administrator confirmed awareness of the kitchen's condition. The DM acknowledged that the kitchen was not up to cleanliness standards and mentioned ongoing efforts to clean and retrain staff. The Administrator was aware of the grime issue and stated that efforts to scrape it off the wall were unsuccessful, leading to plans for wall replacement. Review of the facility's policies and cleaning schedules indicated that the kitchen should be cleaned daily, but these standards were not met.
Rodent Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents. During a group interview with nine residents, it was revealed that while the new pest control company had successfully reduced the number of insects, there was still a significant issue with mice. Two residents even mentioned having pet mice in their rooms, which they fed and allowed on their beds. A dead rat was also observed in an air vent in a supply closet containing medical supplies. The Regional Maintenance Director, on his first day, was unaware of the dead rat, and the Administrator acknowledged the ongoing rodent issue despite weekly treatments by the new pest control vendor. The Director of Nursing (DON) and the Administrator noted that some residents were feeding the mice, complicating efforts to eradicate them. Despite multiple discussions with residents about the health risks posed by the rodents, the problem persisted. The facility's Infection Control Policy aimed to maintain a safe and sanitary environment, but the presence of rodents indicated a failure to meet these objectives.
Failure to Ensure Privacy for Residents with Urinary Catheters
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents, Resident #33 and Resident #72, by not covering their urinary catheter drainage bags with privacy bags. Observations on multiple occasions revealed that the urine content of the bags was visible to other residents, visitors, and facility employees. Both residents were seen in the dining room without privacy bags on their catheter drainage bags. Resident #33, an elderly male with diagnoses including congestive heart failure and prostate hypertrophy, and Resident #72, an elderly male with acute kidney failure and major depression disorder, were both affected by this deficiency. Additionally, neither resident had a comprehensive care plan in place for their urinary catheters, further indicating a lapse in care planning and execution. Interviews with facility staff, including the CRC, RN, and DON, confirmed that the facility's policy required all catheter bags to be covered with privacy bags when residents were outside their rooms. However, it was noted that the privacy bags often fell off, and in some cases, residents removed them out of frustration. The facility's policy on catheter care, dated April 2021, also stipulated the use of privacy covers to preserve resident dignity, which was not adhered to in these instances.
Expired Insulin Pens Found in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of all drugs to meet the needs of the residents. During an inspection of the medication cart for halls A, B, and C, two insulin pens were found with an open date of 03/06/24, which had expired according to the manufacturer's recommendations. The pens were only good for 28 days after being opened. LVN A, who was present during the inspection, admitted that she had not noticed the pens had expired and would have replaced them if she had. The ADON confirmed that it was each nurse's responsibility to check and dispose of expired insulin pens, and acknowledged that administering expired insulin could lead to reduced medication effectiveness. The Administrator also stated that there was no specific person assigned to check the carts for expired medications, and the failure occurred because staff did not pay attention to the dates on the insulin pens. The facility's policy, dated August 2020, indicated that medications should be administered in a safe and effective manner, and this guideline applied to all medications. The manufacturer's instructions for the insulin pens stated that opened pens and vials kept at room temperature or refrigerated would last for 28 days. The failure to adhere to these guidelines and policies resulted in the presence of expired insulin pens in the medication cart, potentially compromising the effectiveness of the medication administered to residents.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. Specifically, the medication cart for halls A, B, and C was observed to be unlocked, unattended, and unsupervised by staff on 04/09/24 at 11:24 AM. LVN A admitted to stepping away and forgetting to lock the cart, which contained several over-the-counter and prescription medications. This lapse in protocol was confirmed during an interview with the ADON, who acknowledged that it was each nurse's responsibility to ensure their carts were locked when not in use. The Administrator was also interviewed and confirmed that the expectation was for medication carts to be locked if staff were not present. The facility's policy, dated August 2020, indicated that all medication storage areas should be locked at all times unless in use and under direct observation. The failure to lock the medication cart was attributed to the nurse getting distracted and forgetting to secure it when stepping away.
Facility Failed to Maintain Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations on two consecutive days revealed grey colored water streaming from a drain clean out located at the end of A Hall, with soiled toilet tissue next to the drain clean out. The grey water ran from the clean out location to the end of the parking lot, pooling in areas next to the exit on A Hall. Despite efforts by the Maintenance Director to address the issue, grey water continued to pool and flow from the drain clean out, creating a hazardous environment. Interviews with the Regional Maintenance Director and the Administrator revealed that the facility was aware of plumbing issues due to the age of the building but was not aware of the active sewage leak. The Regional Maintenance Director confirmed that the wastewater drainage included bodily solids, bodily waste, and paper solids, and acknowledged the hazard it posed to residents and the potential for sickness and groundwater contamination. The facility's Infection Control Policy emphasized maintaining a safe, sanitary, and comfortable environment, which was not upheld in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Midland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Hogan Park | 1 mi | ★★★★★ | 4 | 0 |
| Midland Medical Lodge | 3.6 mi | ★★★★★ | 12 | 0 |
| Mabee Health Care Center | 4.3 mi | ★★★★★ | 10 | 0 |
| Ashton Medical Lodge | 5 mi | ★★★★★ | 4 | 0 |
| Parks Health Center | 14.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.