Inspection Reports for Midlands Living Center

The facility failed to maintain appropriate infection control practices for one of four residents reviewed (Resident #6), including improper hand hygiene and handling of catheter care supplies by staff during observation.

The facility failed to develop comprehensive care plans addressing Enhanced Barrier Precautions for residents with catheters and failed to follow physician's orders for medication administration and respiratory treatments for several residents. The facility lacked policies on monitoring blood pressures and following physician's orders.

The facility failed to develop comprehensive care plans addressing Enhanced Barrier Precautions for residents with catheters, failed to follow physician's medication orders for blood pressure parameters and respiratory treatments, did not use safe transfer techniques such as gait belts, and failed to implement Enhanced Barrier Precautions during catheter care. The facility also lacked policies on care plan development, blood pressure monitoring, medication administration, and safe transfer techniques.

The complaint investigation centered on Staff A's disrespectful and condescending communication with Resident #2, who has dementia. The complaint was substantiated based on video evidence, staff interviews, and facility investigation. Staff A was suspended and terminated following the incident.

The facility failed to ensure that Resident #2 was treated with dignity and respect. Staff A was observed speaking to Resident #2, who has dementia, in a condescending and disrespectful manner, including statements indicating frustration and refusal to assist. The Assistant Director of Nursing intervened and educated Staff A on appropriate interaction. Staff A was suspended and subsequently terminated due to the incident and recording of the interaction.

The facility was found deficient in multiple areas including failure to refer a resident for PASRR after a new diagnosis, incomplete care plans lacking side effect information for anticoagulant medication, inadequate infection prevention practices during blood glucose monitoring and medication administration, and failure to provide required dependent adult abuse training to staff.

The complaint investigation focused on grievances related to call light response times, supervision failures leading to potential accidents and falls, and infection control practices related to COVID-19 positive residents being cohorted with negative roommates. The grievance was substantiated with findings of failure to document and resolve the grievance. Supervision and infection control deficiencies were also substantiated.

The facility failed to establish a grievance policy and properly document and resolve a resident's grievance about call light response times. The facility also failed to provide adequate supervision to prevent accidents for two residents, including one who rolled down an incline toward stairs. Additionally, the facility failed to isolate COVID-19 positive residents in private rooms, cohorting them with COVID-19 negative roommates, increasing the risk of transmission. Several fall risks and unsafe wheelchair use were also documented.