Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
109% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activity programming, pressure ulcer prevention, food service safety, and staff training at Midwestern Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meal service, incomplete and outdated care plans especially for residents with special needs, inadequate activity programming for bedbound residents, failure to provide pressure reduction cushions for at-risk residents, unsanitary kitchen conditions, and failure to ensure all staff received required training.
Deficiencies (6)
Failed to treat residents with respect and dignity during lunch service, causing some residents to wait significantly longer than their tablemates to be served.
Failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for residents, including addressing activity needs and bedbound status.
Failed to provide ongoing activity programs that meet residents' individual preferences and needs, resulting in social isolation and decreased well-being for some residents.
Failed to ensure pressure reduction cushions were present on wheelchairs for residents at high risk for pressure ulcers.
Failed to maintain sanitary conditions in the kitchen, including unclean fryer, dirty dish cart, and unswept floors behind cooking equipment.
Failed to implement and maintain an effective training program for all staff, with one licensed practical nurse lacking required trainings in multiple key areas.
Report Facts
Residents reviewed for resident rights: 15
Residents affected by dignity deficiency: 2
Residents reviewed for care plans: 2
Residents reviewed for pressure ulcer care: 3
Staff training deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Charge Nurse for Dining | Named in relation to dignity issues during meal service for Residents #25 and #53. |
| DM | Dietary Manager | Interviewed regarding meal service procedures and kitchen sanitation. |
| Activity Director | Interviewed regarding activity programming and care planning for Resident #8. | |
| C.N.A. A | Certified Nursing Assistant | Provided observations about Resident #8's care and activity engagement. |
| RN C | Charge Nurse for Hall C | Interviewed regarding pressure ulcer prevention and wheelchair cushion for Resident #34. |
| CNA D | Certified Nursing Assistant | Interviewed regarding wheelchair cushion use for Resident #34. |
| DON | Director of Nursing | Interviewed regarding pressure ulcer prevention and staff responsibilities. |
| Administrator | Interviewed regarding staff training and pressure ulcer prevention. | |
| ADMN | Administrator | Interviewed regarding staff training program and deficiencies for LPN E. |
| HR Coordinator | Interviewed regarding staff training records and deficiencies for LPN E. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding verbal abuse and failure to report abuse involving Resident #1 and staff member LVN B.
Complaint Details
The complaint involved verbal abuse of Resident #1 by LVN B on 5/4/25, including rude language, gestures (flipping off), and provocation. Multiple staff failed to report the abuse to the administrator or DON. Police were called and intervened. The facility administration was unaware of the abuse until surveyor intervention on 5/18/25. Immediate Jeopardy was identified on 6/4/25.
Findings
The facility failed to keep residents free from abuse, specifically verbal abuse by LVN B towards Resident #1, and failed to report the abuse timely. Immediate Jeopardy was identified on 6/4/25 due to the severity of the verbal abuse and failure to report. The facility implemented a Plan of Removal including staff training, neighbor rounds, and monitoring to prevent further abuse.
Deficiencies (3)
Failed to protect Resident #1 from verbal abuse by LVN B, including rude language, gestures, and provocation.
Failed to implement written policies and procedures to prevent abuse, neglect, and theft.
Failed to timely report suspected abuse and neglect, including verbal abuse and police intervention, to the administrator and proper authorities.
Report Facts
Residents reviewed: 16
Staff trained on abuse and neglect: 49
Staff trained on verbal abuse quiz: 52
Shifts worked by LVN B between 05/04/2025 and 05/18/2025: 10
Staff in leadership team for neighbor rounds: 12
Residents involved in life satisfaction rounds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in verbal abuse finding and termination for abuse |
| LVN A | Licensed Vocational Nurse | Witnessed abuse incident, called police, and reported to DON |
| CNA D | Certified Nursing Assistant | Witnessed abuse, failed to report, received final warning |
| CNA C | Certified Nursing Assistant | Witnessed abuse, failed to report, received final warning |
| DON | Director of Nursing | Abuse coordinator, interviewed about abuse incident and reporting |
| ADM | Administrator | Abuse coordinator at time of survey, involved in Plan of Removal |
| Police Officer | Responded to abuse incident and de-escalated situation | |
| SW | Social Worker | Conducted peer interviews and life satisfaction rounds |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to promptly address grievances voiced during Resident Council Meetings and issues related to food service safety.
Complaint Details
The complaint investigation focused on grievances raised by residents during Resident Council Meetings about unresolved concerns, lack of follow-up, and inadequate communication from the Administrator. Interviews with residents, the Social Worker, Activity Director, and Administrator confirmed these issues. Additionally, concerns about food safety and sanitation in the kitchen were observed and documented.
Findings
The facility failed to act promptly on resident grievances from Resident Council Meetings, resulting in minimal harm or potential harm to residents' quality of life. Additionally, the facility failed to maintain food service safety standards, including improper food storage, expired food items, unsanitary kitchen conditions, and exposure of sanitized utensils to contaminants.
Deficiencies (2)
Failure to honor the resident's right to organize and participate in resident/family groups by not addressing grievances promptly and not documenting follow-up actions for Resident Council Meetings.
Failure to store, prepare, distribute and serve food in accordance with professional standards, including soiled appliance surfaces, expired food items, unlabeled and undated opened food packages, and exposure of sanitized utensils to contaminants.
Report Facts
Resident Council grievance reports: 12
Resident attendance: 9
Resident attendance: 10
Resident attendance: 11
Expired prune juice cartons: 9
Expired milk cartons: 3
Expired buttermilk containers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Council President | Provided information about Resident Council Meetings and grievances during interviews | |
| Social Worker | Provided information about grievance reports and grievance tracking | |
| Activity Director | Recorded Resident Council meeting minutes and described grievance process | |
| Administrator | Discussed grievances with residents and described smoking policy enforcement | |
| Dietary Manager | Removed expired food items and described kitchen cleaning schedules |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, assessments, care planning, activities of daily living, medication management, staffing postings, and medical record maintenance at Midwestern Healthcare Center.
Findings
The facility was found deficient in maintaining a clean and homelike environment, accurate resident assessments, comprehensive care plans, assistance with activities of daily living, proper medication cart security, posting of nurse staffing information, and maintaining complete medical records. These deficiencies posed risks of unsanitary conditions, inadequate care, incomplete documentation, and potential medication diversion.
Deficiencies (7)
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for resident rooms, including soiled sheets and unclean walls, curtains, and floors.
Failed to have assessments that accurately reflect the status of a resident, including behavioral state and documentation of 1:1 observations.
Failed to develop and implement a comprehensive person-centered care plan addressing physical, verbal, and sexual aggressive behaviors, visual function, risk for falls, pressure ulcers, antianxiety medications, and 1:1 staffing.
Failed to provide necessary assistance with activities of daily living for a resident, including incomplete ADL documentation and missed care.
Failed to post updated daily nurse staffing information for multiple consecutive days.
Failed to ensure medication carts were secured and locked when unattended, risking drug diversion.
Failed to maintain complete medical records, including lack of physician orders for 1:1 observations and incomplete documentation.
Report Facts
Dates nurse staffing posting not updated: 5
Days with no ADL documentation for Resident #3 in July 2023: 11
Days with no ADL documentation for Resident #3 in August 2023: 15
Days with no ADL documentation for Resident #3 in October 2023: 31
Dates 1:1 staffing provided for Resident #1: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Named in multiple interviews regarding expectations for sheet changes, ADL completion, medication cart security, and assessment and care plan deficiencies. |
| MDS Coordinator | Responsible for assessments and care plans; reported inadequate training and requested help. | |
| LVN F | Licensed Vocational Nurse | Observed leaving medication cart unlocked. |
| ADON | Assistant Director of Nursing | Observed leaving medication cart unlocked. |
| Administrator | Stated DON was responsible for nurse staffing posting. | |
| Housekeeping Manager | Observed unclean resident room and committed to resolving issues. |
Inspection Report
Routine
Deficiencies: 4
Date: May 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, PASARR referrals, and nutritional services at Midwestern Healthcare Center.
Findings
The facility failed to complete a comprehensive assessment within 14 days after a significant change in condition for one resident, failed to refer one resident for PASARR review after new mental illness diagnoses, failed to develop a comprehensive care plan within 7 days for one resident, and failed to provide an acceptable dessert substitute according to the posted menu for many residents.
Deficiencies (4)
Failed to ensure a comprehensive assessment was completed within 14 days after a significant change in condition for Resident #8.
Failed to refer Resident #54 for PASARR review following new mental illness diagnoses.
Failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for Resident #65.
Failed to follow the menu for all residents reviewed for food preferences and failed to provide an acceptable substitute for dessert at lunch.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Many
Date survey completed: May 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Interviewed regarding assessment and PASARR deficiencies; responsible for MDS assessments and PASRRs | |
| DON | Interviewed regarding responsibility for assessments and care planning | |
| SW | Interviewed regarding care conference attendance and care plan development | |
| DM | Interviewed regarding food service and dessert substitution |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 15, 2023
Visit Reason
The inspection was conducted as an annual survey of Midwestern Healthcare Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met required standards at the time of the survey.
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