Midlands Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Midlands Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF908Apr 8, 2024

  Based on review of facility policy, interviews, and record review, the facility failed to ensure Resident (R)1 and R2 was free from electrical hazards. On 04/08/24 at 4:00 PM, the Administrator and Director of Nursing were notified that the failure to maintain all mechanical, electrical, and patient care equipment in safe operation constituted Immediate Jeopardy (IJ) at F908. On 04/08/24 at 4:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 12/15/23. The IJ was related to 42 CFR 483.90 - Physical Environment. On 04/08/24 at 6:18 PM, the facility presented an acceptable plan of removal of the IJ. […]

• No harm, potential for more than minimal, patternF812Sep 11, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried plates and bowls prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 72 of 86 residents who received dietary servicesFindings include:Review of the facility policy titled, Storage and Cleaning of Dishes and Utensils dated 07/21/23 revealed, Proper ware-washing and storage is also important in food safety . Inspect clean dishes for debris and send back through the dish machine as needed . Clean dishes, silverware, pots, pans, and utensils are stored in a clean dry area at least 6 [sic] [inches] off the floor. […]

• No harm, potential for more than minimal, patternF887Sep 11, 2025

  Based on record review, interview, review of the Centers for Disease and Prevention (CDC) recommendations, and facility policy review, the facility failed to ensure that 4 residents (Resident (R)6, R16, R25, and R46) out of 5 reviewed, were offered the COVID-19 vaccine booster out of a total sample of 26 residents. This failure had the potential for the residents and/or their responsible party of not being informed to make a decision if they wanted the vaccine and a potential risk of contracting COVID-19.Findings include:Review of the facility's policy titled, Infection Prevention and Control Policies and Procedures Subject: Immunization recommendations for patients/residents and health care workers revised 05/15/23 indicated .The facility will track all staff and resident vaccination… […]

• No harm, potential for more than minimal, patternF761Aug 28, 2024

  Based on the facility policy, observations and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use for residents in 3 of 4 med carts and 2 of 2 medication rooms. The facility further failed to ensure medications that were discontinued, or the medications for discharged residents were not stored in a med room on the North Hall. The facility additionally failed to ensure personal snacks were not stored on the North Hall front med cart. Review of the facility policy titled, Section 5 - Medication Disposal and Returns, states under procedures: 1. […]

• No harm, potential for more than minimal, patternF677Sep 28, 2022

  Based on review of facility policy, record review, observations, and interviews, the facility failed to assist residents with Activities of Daily Living (ADL) care for 6 of 8 residents (R)13, R18, R25, R68, R74, and R78, who were dependent for ADL care in a total sample of 21 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, Optimal Function, dated 08/30/17 revealed, The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. 1. Review of R13's Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]