Midlothian Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 3 (Resident #37, Resident #40 and Resident #55) of 12 residents reviewed for pharmacy services. The facility failed to ensure Every controlled drug administered and documented in the MAR was accurately reflected in the controlled drug log form of Resident #37, Resident #40 and Resident #55. Discarding 20 prefilled syringes that expired on [DATE] and were stored in the medication storage room, containing 0.5ml dose of influenza vaccine. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #1 and Resident #2) reviewed for infection control. The LVN did not properly use EBP personal protective equipment during wound care for Resident #1. CNA A did not sanitize his hands between glove changes during peri-care for Resident #2. These failures could place the residents at risk of infection transmission, sepsis (a life-threatening medical emergency that occurs when the body's response to an infection causes damage to its own organs and tissues), and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the residents' representative and physician of the changes in the resident's physical and mental health for one (Resident #1) of seven residents reviewed for notification of changes. The facility failed to ensure Resident #1's RP and Physician were notified when he was found on the floor after a fall on 11/20/2025. This failure placed residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #1), reviewed for pharmaceutical services, in that: The facility failed to ensure that Resident #1 was administered Morphine 10mg ER in accordance with the physician's order when the resident was administered Morphine 100mg instead. This failure placed the resident at risk for adverse reactions that could have been life threatening, and which lead to the hospitalization of Resident #1 for acute respiratory distress.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #1) of 6 residents reviewed for medication administration. Resident #1 was administered Morphine 100mg ER instead of Morphine 10mg ER as ordered, which was outside of physician parameters. This failure could place residents at risk for not receiving the intended therapeutic benefit of their prescribed medication, worsening or exacerbating chronic medical conditions, placing residents at risk for adverse reactions that could be life threatening, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established guidelines and was followed for 2 (Resident #7 and Resident #30) of 6 residents reviewed for food and nutrition services . The facility failed to serve Resident #7 and Resident #30 the posted lunch and dinner on Sunday 12/01/2024. This failure could place residents at risk of poor intake, chemical imbalance, and/or weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen and one (Nourishment room [ROOM NUMBER]) of two nourishment rooms reviewed for food and nutrition services. 1. The facility failed to ensure the DA wore an effective hair and beard restraint while in the kitchen. 2. The facility failed to ensure expired instant oatmeal packets, vegetable juice blend cans, pure corn starch and vitamin D milk items were discarded. 3. The facility failed to ensure the nourishment room refrigerator contained items with a name and date on a lunchbox in Nourishment room [ROOM NUMBER]. These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections for medical supplies stored in 1of 2 Medication storage rooms (800 Hall) and for 1 of 2 medication carts (800 Hall) reviewed for infection control /drug storage. The facility failed to ensure expired and contaminated medical supplies were removed from the medication storage room and 1 of the medication carts (located by the 800 Hall). This failure could place residents at risk for infection, ineffective treatment, and harm.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of six residents (Resident #6) reviewed for activities of daily living . The facility failed to ensure Resident #6 was fed her lunch in a timely manner. This failure could place residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident # 38) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #38 was free from physical abuse. This failure placed residents at risk for of physical and psychosocial harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store foods properly and maintain a sanitized food preparation area for the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to properly seal food containers in the facility's only pantry, walk-in cooler, and freezer. 2. The facility failed to maintain clean kitchen surfaces/appliances. These failures placed residents at risk of exposure to food borne pathogens.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, in that: The facility failed to submit staffing information to CMS for the 3rd quarter of the Fiscal Year 2023. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents (Residents #16 and #18) reviewed for call lights in that: The facility failed to ensure Residents #16 and #18's call lights were within reach. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 (Residents #79 and #55) of 5 residents reviewed for usage of wrist blood pressure monitor, as indicated by: MA A observed not cleaning and disinfecting the wrist blood pressure monitor while using it on Resident # 79 and Resident #55. This failure could place the residents at the facility at risk of transmission of disease and infection.