Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0637
Assess the resident when there is a significant change in condition
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews, the facility failed to ensure a comprehensive assessment was completed
within 14 days after a significant change in the physical or mental condition for 1 of 3 residents (Residents
#8) whose records were reviewed for assessments.
Residents Affected - Few
The facility failed to capture a comprehensive MDS assessment after Resident #8 returned to the facility
from the hospital and had a significant decline.
This failure placed could place residents at risk for not being assessed for a change in condition and the
need to revise their care plans to address changes in condition and develop interventions to meet their
needs for care assistance and treatments.
The findings included:
Record review of Resident #8's face sheet, generated 5/23/2023, reflected Resident #8 was an [AGE]
year-old female who was initially admitted to the facility on [DATE], with a readmission date of 03/07/2023.
The resident had the following diagnosis, which included: bacteriemia (presence of bacteria in the
bloodstream), pressure ulcer sacral region; stage 2 (wound on the bottom area that is due to pressure), and
abnormal findings in urine (urine showed presence of something abnormal).
Record review of Resident #8's MDS Schedule reflected the last assessment as a Quarterly assessment
on 3/07/2023 and, not a significant change assessment.
Record review of Resident #8's Quarterly MDS revealed in the following sections- N: antibiotics were given
the last 7 days. Section O: IV medications were given.
Interview with the ADON on 5/23/2023 at 3:00 PM, she revealed that the resident was sent to the hospital
due to a decline in her health. She stated that the resident has had a significant decline and a significant
change MDS assessment should have been done when she returned to the facility on IV antibiotics. She
revealed this failure could place the residents at risk for inadequate care. She revealed that it was her
responsibility to make sure that the assessments were done accurately.
Interview with the DON on 05/23/2023 at 12:00 PM revealed that it was the ADON's (who was the past
MDS coordinator) responsibility to make sure the assessments are were completed accurately. The new
MDS coordinator was in training and had not assumed the responsibility of completing the MDS
assessments. She stated that this failure could cause her to miss care areas that would trigger on a
significant change assessment.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
675128
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675128
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Midwestern Healthcare Center
601 Midwestern Pkwy
Wichita Falls, TX 76302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0637
Interview with the ADON on 05/24/2023 at 2:30 PM revealed that they did not have a policy covering MDS
assessments. She revealed that they followed the RAI guidelines.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675128
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675128
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Midwestern Healthcare Center
601 Midwestern Pkwy
Wichita Falls, TX 76302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review the facility failed to refer 1 of 4 residents whose PASARR evaluations were
reviewed (Resident #54) who had newly evident mental disorders in that:
The facility failed to refer Resident #54 for PASARR review following new mental illness diagnoses.
This deficient practice could affect 4 residents who had qualifying diagnoses with a negative PASARR Level
1 evaluation.
The findings included:
Record review of Resident #54's Face Sheet, dated 05/24/2023, revealed a [AGE] year-old male, admitted
to the facility on [DATE] with Admitting diagnosis of Major Depressive Disorder (a persistent feeling of
sadness and loss of interest) and anxiety disorder (excessive and persistent worry and fear about everyday
situations). Resident #54 had a diagnosis of bipolar II disorder (a mood disorder characterized by
hypomania and major depression) added on 01/13/2022 and schizoaffective disorder, bipolar type
(abnormal thought processes and an unstable mood) added on 10/25/2022.
Record review of Resident #54's Physician Orders Summary Report, dated 05/24/2023, revealed orders for
buspirone 10mg for anxiety disorder, fluoxetine 20mg for depression, and Latuda 20mg for schizoaffective
disorder, bipolar type.
Record review of Quarterly MDS, dated [DATE], revealed Resident #54 had a BIMS score of 13 out of 15,
which indicated the resident was cognitively intact. Resident #54 had active diagnoses which included
anxiety disorder, depression, bipolar disorder, and schizophrenia (schizoaffective disorder). Resident #54
received antianxiety and antidepressant medications.
Record review of Resident #54's Care Plan, last revised on 03/21/2023, revealed care plans for: a)
Resident #54 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to
a diagnosis of Depression, Anxiety; b) Resident #54 has potential for ADL selfcare performance deficit
related to diagnosis of Depression c) Resident #54uses anti-anxiety medication, Buspar, related to anxiety
disorder; d) Resident #54 uses antidepressant medication, Zoloft, related to Depression e) Resident #54
has diagnosis of depression and bipolar disorder. At risk for mood/behavioral changes; f) Resident #54 has
a psychosocial wellbeing problem related to diagnosis of Major Depressive Disorder and anxiety.
Record review of Resident #54's PL1, dated 10/31/2021, revealed Resident #54 was negative for mental
illness. An updated PL1 was not completed after admission or diagnosis of bipolar II disorder was added on
01/13/2022 and schizoaffective disorder, bipolar type added on 10/25/2022.
In an interview on 05/24/2023 at 10:04 am, the ADON said she was the MDS Coordinator and was
responsible for the PASRRs until recently. She said an updated PL1 should have been completed for
Resident #54 since he had a diagnosis of mental illness upon admission, but it was not completed. She
said this failure could prevent or delay services the resident was entitled too.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675128
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675128
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Midwestern Healthcare Center
601 Midwestern Pkwy
Wichita Falls, TX 76302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Record review of the facility's PASRR Policy A1500: Preadmission Screening and Resident Review
(PASRR), dated as last reviewed on 01/24/2023, revealed the following:
A resident with MI or ID/DD must have a Resident Review (RR) conducted when there is a significant
change in the resident's physical or mental condition. Therefore, when a significant change in status
assessment is completed for a resident with MI or ID/DD, the nursing home is required to notify the State
mental health authority, intellectual disability, or developmental disability authority (depending on which
operates in their state) in order to notify them of the resident's change in status.
Event ID:
Facility ID:
675128
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675128
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Midwestern Healthcare Center
601 Midwestern Pkwy
Wichita Falls, TX 76302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop a comprehensive care plan within 7 days after
completion of the comprehensive assessment for 1 of 6 residents (Resident #65) whose records were
reviewed for assessments and care plans, as well as having an IDT team present at the care conference.
The facility failed to ensure Resident #65 had a comprehensive care plan developed and updated within 7
days following the completion of the admission comprehensive assessment.
This failure could place residents at risk of not have having their care plans completed accurately and
timely.
Findings included:
Record review of Resident #65's face sheet revealed Resident #65 was a [AGE] year-old female who was
admitted to the facility 02/22/2023. Resident #65 had diagnoses which included hemiplegia (paralysis of
one side of the body), hypertension (high blood pressure), dysphagia (difficulty swallowing) and congestive
heart failure (heart cannot pump blood adequately due to failure).
Record review of Resident #65's admission MDS assessment, dated 03/04/2023, revealed the following:
Section C revealed the resident was unable to complete the BIMS interview. Section K revealed a weight of
139 pounds. Section G revealed: Bed mobility- extensive, Transfers- extensive, walk-in room- did not occur,
walk in corridor- did not occur, locomotion on unit- extensive, locomotion off unit- extensive, dressingextensive, toilet use- extensive and personal hygiene- extensive. Section Z revealed that the RN signature
date was for 03/10/2023.
Record review of Resident #65's care plan progress note, dated 03/09/2023, for activities reflected: the
resident had adequate hearing without a hearing aid. The resident had unclear speech, was rarely/never
understood, and understood others. The resident had adequate vision with glasses. The resident reported
lacking energy. No delirium or delusions. The resident was somewhat able to participate well with
interviews. The resident planned to remain in the facility. There was no discharge planning at this time.
Record review of Resident #65's Care Conference, dated 03/09/2023, did not have a Registered Nurse
attend the Comprehensive admission Care Conference.
Record review of Resident #65's admission care plan progress note, dated 03/09/2023, showed the care
conference was conducted before the MDS admission assessment was completed.
Record review of Resident #65's admission care plan, dated 03/09/2023, revealed the CAAS sections were
not completed until 04/12/2023.
Interview on 05/23/2023 at 11:00 AM, the SW revealed that an RN did not attend the Care Conference on
03/09/2023. She revealed that it was the admission care conference and there had not been another care
conference since then. She was unaware that a RN had to be present for the comprehensive admission
care conference meeting.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675128
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675128
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Midwestern Healthcare Center
601 Midwestern Pkwy
Wichita Falls, TX 76302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 05/23/23 at 11:23 AM, the ADON revealed that they got behind with care plans and the
meetings, but corrected them with corporate leadership and interventions. She stated that she was sent to
another building for extra training. She revealed the care plan was created a month late on 04/12/2023.
Interview on 05/23/2023 at 12:00 PM the DON revealed that she was unaware that the admission care plan
meeting had been completed without an RN. She stated that it was her expectation that an RN attend and
that the care plan be completeled timely.
Observation and interview on 05/23/2023 at 1:48 PM revealed, Resident #65 was observed sitting in her
wheelchair. She was unresponsive to questions and was unable to communicate.
Record review of the facility's care planning policy, dated revised October 2022, titled Care Plans,
Comprehensive Person- Centered revealed:
Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and
timetables to meet the residence physical, psychosocial, in functional needs is developed and implemented
for each resident.
Policy Interpretation and Implementation:
1)
The intra-disciplinary team, in conjunction with the resident and his or her family or legal representative,
develop and implement a comprehensive, person- centered care plan for each resident. The 80 team may
include but not limited to the attending physician a registered nurse who has responsibility for the resident .
3)
The IDT may include but not limited to: A registered nurse who has responsibility for the resident
4)
The care plan interventions are derived from a thorough analysis of the information gathered as part of the
comprehensive assessment.
9)
The comprehensive person-centered care plan will: Include measurable objectives and time frames.
Describe any specialize services. Incorporate identify problem areas reflect treatment goals, timetables,
and objectives in measurable
12) The comprehensive, person-centered care plan is developed within seven days of the completion of the
required comprehensive assessment MDS.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675128
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675128
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Midwestern Healthcare Center
601 Midwestern Pkwy
Wichita Falls, TX 76302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review, the facility failed to follow the menu for all residents
reviewed for food preferences.
Residents Affected - Many
The facility failed to provide an acceptable substitute for dessert at lunch when they served whipped cream
with graham cracker crumbs instead of the scheduled Key Lime pie.
This failure could place residents at risk of feeling that their preferences are not being met.
Findings include:
Observation on 05/22/2023 at 12:00 PM revealed residents, sitting in the dining room, were served small,
clear plastic bowls filled with whipped cream, sprinkled with graham cracker crumbs.
Observation on 05/22/2023 at 12:02 PM revealed food trays for residents, dining in their rooms, contained
bowls that appeared to be whipped cream covered with graham cracker crumbs.
Observation on 05/22/2023 at 12:05 PM revealed the daily posted menu listed Key Lime pie as the dessert
for the day.
Observation on 05/22/2023 at 12:15 PM revealed a test tray which contained a bowl of whipped cream
sprinkled with graham cracker crumbs. The dessert was sampled and was not flavored in any way.
In interview on 05/22/2023 at 12:04 PM, with Residents #41 and #20, sitting in the dining room, revealed
the facility never served Key Lime pie and just put whipped cream flavored with lime juice in a bowl and
called it dessert.
In an interview on 05/22/2023 at 12:09 PM, the DM said they did not make or buy Key Lime pie for the
residents and she forgot to buy lime juice to add to the whipped cream. She said they did not make a
substitute for the residents. The substitute that day was pudding.
Record review of the facility policy titled Substitutions, Administrative Policies, 2001 MED-PASS, Inc
(Revised March 2004) revealed the following:
Policy Statement
Food substitution will be made as appropriate or necessary.
Policy Interpretation and Implementation
1.
The food services manager, in conjunction with the clinical dietician, may make food substitutions as
appropriate or necessary. The food services shift supervisor on duty will make substitutions only when
necessary.
2.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675128
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675128
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Midwestern Healthcare Center
601 Midwestern Pkwy
Wichita Falls, TX 76302
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
The food services manager will maintain an exchange list identifying the seven (7) exchanges of food
groups. When in doubt about an appropriate substitution, the food services manager will consult with the
dietician prior to making the substitution.
3.
Residents Affected - Many
Residents' likes and dislikes will be considered when making substitutions.
4.
All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations
of substitutions must include the reason for the substitution.
5.
The food services manager will review the substitutions regularly to avoid recurrences when possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675128
If continuation sheet
Page 8 of 8
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FAQ · About this visit
Common questions about this visit
What happened during the May 24, 2023 survey of Midwestern Healthcare Center?
This was a inspection survey of Midwestern Healthcare Center on May 24, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Midwestern Healthcare Center on May 24, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assess the resident when there is a significant change in condition"
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.