Inspection Reports for
Nexion Midwestern Healthcare Center

The facility failed to protect and promote the rights of each resident.

The facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support a resident in the resident's 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.

The facility did not develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured.

The facility failed to make sure that the resident with pressure ulcers receives appropriate treatment and services.

The facility did not store, cook, and give out food in a safe and clean way.

The facility failed to provide its staff, individuals providing services under a contractual arrangement and volunteers orientation, training, and in-service meetings consistent with their expected roles.

The facility failed to the meet Life Safety Code requirements for an existing Health Care Occupancy.

The facility failed to make sure any fenced outside areas that block access to the street meet certain requirements.

The facility failed to have a person licensed by the State Fire Marshal's office inspect and service automatic fixed fire extinguishment systems mounted in kitchen range hoods at least once every six months in accordance with NFPA 96; failed to maintain, onsite, a written and signed report of the inspection and service performed; or failed to keep the hood, exhaust ducts, and filters clean and free of accumulated grease.

The facility failed to make sure electronic locks on gates were installed according to the National Electrical Code and were made for use outdoors, and that gates keyed locks are only used where allowed.

The facility failed to make sure electrical extension cords or multi-receptacle plug-in adaptors were not used as a substitute for approved wiring methods in the facility.

The facility failed to include procedures for conducting a fire drill on each work shift at least once per quarter with at least one fire drill conducted each month; or the facility failed to fill out the form titled "FIRE DRILL REPORT" for a fire drill conducted.

The facility failed to evaluate and change the plan as needed within 30 days after an emergency situation, remodeling or adding on to the facility or at least annually.

Enforcement action (2025-10-08): The facility did not protect each resident from all abuse, physical punishment, and being separated from others.

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.

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.

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.

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.

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.