Midlothian Healthcare Center

In the surveyor’s words

From the most serious findings on record at Midlothian Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure the resident was free from neglect for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to ensure Resident #1 was assessed and treated for a disseminated rash (rash on several parts of the body) that was first identified 05/03/23 by RP #2; the facility failed to ensure Resident #1 was taken to his dermatologist appointment on 07/26/23 on time, which caused the appointment to be rescheduled on 08/21/23 at which time Resident #1 was diagnosed with scabies and treatment was initiated. As a result of the facility's failures Resident #1 suffered continuous pain, itching and discomfort for 3 months, and other residents and staff were exposed to scabies. […]

• Immediate jeopardy, isolatedF684Aug 28, 2023

  Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to identify a disseminated rash on Resident #1 prior to identification by RP #2 on 05/03/23; the facility further failed to ensure weekly skin checks were completed and documented in a timely manner in that 4 weekly skin checks were not done for Resident #1 since identification of his rash on 05/03/23. […]

• Actual harm, isolatedF755Dec 18, 2024

  Based 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. […]

• Actual harm, isolatedF760Dec 18, 2024

  Based 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 . The findings included: An interview with the resident was attempted via telephone on November 1, 2024. […]

• Actual harm, isolatedF600Oct 26, 2023

  Based 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. Findings include: Record review of Resident # 38's admission record indicated that Resident # 38 was a [AGE] year-old male who was residing at Midlothian Healthcare Center sine 4-28-2023. […]