Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Midlothian during CMS and state inspections, most recent first.
A facility failed to provide water and water pitchers at the bedside between meals for several residents with thin liquid orders. During observation, a CNA and an LPN/DON noted residents without water or with empty pitchers, while the DON confirmed that residents not on fluid restriction should have water available at the bedside. Records showed the affected residents had thin liquid orders and care plans directing that diet orders be followed.
Nonfunctional Bed Frames and Electric Bed Not in Good Repair: The facility failed to ensure that several residents' bed frames had working manual lift mechanisms and that one resident's electric bed was in good repair. During observation, an electric bed control would not function even after the cord was found and reconnected, and multiple manual crank bed frames for other residents were observed not to work properly. A CNA stated the crank handles could not lift the beds, and the Maintenance Director acknowledged some crank handles were rusted and had been repaired with oil spray.
Staff members did not consistently wear visible ID badges showing their name, licensure status, and position, as required by law. Several staff were observed without badges or with incomplete identification, and cognitively intact residents expressed concern about not being able to verify who was providing their care. Facility leadership was unaware of a policy on ID badges, and alternative identification methods were inconsistently used.
Insufficient nursing staffing led to delayed care, medication errors, and incomplete restorative services for multiple residents. Surveyors observed residents with long nails, unshaved facial hair, incorrect LALM settings, unsecured catheter tubing with blood-tinged urine, and IVPB rate discrepancies. Several residents missed scheduled 9 a.m. meds within the required window, and restorative care for residents with contractures, paralysis, and ROM limitations was inconsistently provided or undocumented. The administrator stated the facility had no staffing policy and staffing was based on resident acuity and census.
Improper Labeling and Storage of Medications: An IVPB infusing through a resident’s IV access was not labeled with the resident’s name, and none of the supplement check boxes on the label were marked. Medication storage issues were also observed in two unit med rooms: refrigerated meds were left on top of a food refrigerator, one locked box with Ativan solution read 79F, another med room was unlocked and unsupervised, and its refrigerator was 67F with heavy ice buildup and repeated log entries noting ice.
Outside Dumpster Left Open: The facility failed to keep the outside dumpster closed. The dumpster was observed open on two separate occasions with a swarm of flies flying inside and outside it, and both the Dietary Mgr and Housekeeping Dir/Head of Laundry stated it should be kept closed. Facility policy required the dumpster lid to be tightly closed and kept closed.
Failure to Provide Grooming and Nail Care: The facility failed to provide ADL grooming and nail care for dependent residents. A resident with severe cognitive impairment was observed with long facial hair and long toenails, and an LPN acknowledged the nails needed clipping. Another resident with hemiplegia and moderate cognitive impairment had long nails with debris and stated he could not care for them. A cognitively intact resident with Parkinson's disease and arthritis was observed with filthy fingernails and stated she repeatedly asked for help. The facility's policy required nail care and cleaning during bathing.
A resident's IVPB was found infusing at 250 ml/hr even though the label indicated 83 ml/hr. In addition, multiple residents were still highlighted red on the EMAR because their scheduled 9am meds had not been given within the required time window, and staff acknowledged the doses were late or not yet administered.
A CNA passed multiple meal trays to several residents without performing hand hygiene between residents, and a restorative aide handled dirty meal trays and then assisted a resident with eating without cleaning hands first. The DON/IP stated hand hygiene is done while passing trays to prevent transferring bacteria to other residents, and facility policy required routine hand hygiene and barrier precautions.
Failure to refer two residents with possible serious mental disorders for PASRR Level II review. The facility did not send residents with newly evident or possible SMI/SMD to the state-designated authority for further assessment as required. One resident had a history including major depressive disorder severe without psychotic features and schizoaffective disorder bipolar type, along with multiple other medical conditions. The facility’s PASRR policy required referral of level II residents and residents with possible serious mental disorder, ID, or related condition for state review.
Failure to develop pain management care plans with measurable goals and resident preferences for two residents receiving pain meds. One resident with stroke-related deficits, diabetic neuropathy, and an amputation reported severe pain and said Norco had run out, while the record showed active pain med orders and pain assessments but no care plan. Another resident receiving PRN ibuprofen also had pain assessment orders but no pain care plan. The DON stated residents on pain management should have a care plan to track pain levels and evaluate treatment effectiveness.
The facility failed to ensure proper LALM policy, staff knowledge, and mattress settings for three residents with pressure ulcers. A resident with a heel PU was observed on a LALM set far above his weight, another resident with an unstageable buttock PU and MASD was on a LALM in static mode with staff unable to explain the setting, and a third resident with a stage 3 back PU was also on a LALM set well above his weight. The Administrator stated the facility had no LALM policy and relied on manufacturer guidelines.
Failure to assess and provide restorative care and devices for two residents. One resident with MS had contracted hands and arm, a deformed foot, blank PROM documentation, and no restorative devices in use despite reported need. Another resident with dementia and hip OA had AROM documentation, but was not on the restorative schedule and had difficulty lifting both feet. Staff interviews confirmed missing restorative documentation and uncertainty about restorative assignments.
A resident with an indwelling urinary catheter and diagnoses including hydronephrosis with renal and ureteral calculous obstruction had cranberry-colored, blood-tinged urine while staff noted the catheter was not secured to the leg. The RN stated the urine appeared dark red with blood, the resident was taking Eliquis and Plavix, and the catheter showed notable tension from bag placement and lack of securement to prevent trauma.
Enteral feeding orders lacked required details, and a resident with a G-tube did not receive the full prescribed Jevity 1.5 cal volume. An LPN stated the feeding was stopped before the ordered duration ended, and the resident received about 650 ml instead of the ordered 900 ml. The DON acknowledged tube feeding orders should include the amount, formula, and duration, and the resident had a documented weight loss over a short period.
Respiratory care was not provided as ordered for a resident with asthma, sleep apnea, acute and chronic respiratory failure, and pneumonia. Staff observed the resident’s unused nasal cannula hanging over the O2 concentrator without a date or label, the O2 humidifier overdue for change, and the CPAP mask left out on top of a storage bin. The resident’s orders required weekly changing and dating of O2 tubing and humidifiers, along with daily CPAP/BiPAP reservoir care and use of O2 as ordered.
A resident’s scheduled Citalopram, Mirtazapine, and Oxybutynin were unavailable when an LPN attempted to dispense them. The EMAR showed the pharmacy had rejected the order and listed the meds as leave of absence, and the DON could not locate them in electronic med storage or provide a list of stored meds. The facility policy required meds to be reordered at least 3 days in advance to ensure an adequate supply.
Medication administration errors exceeded the allowed rate, with 6 errors in 25 opportunities. A resident had ordered meds unavailable, another resident received only one tablet instead of the ordered 40 mg dose of Lisinopril, and an RN crushed an ER Oxybutynin tablet before giving it. Staff interviews confirmed the missing meds, the incorrect tablet count, and that the medication was extended release.
A facility failed to follow its med administration policy and committed significant med errors for three residents. An LPN could not locate ordered meds for one resident, another resident received only one tablet of a 40 mg lisinopril order instead of four 10 mg tablets, and an LPN crushed an oxybutynin ER tablet before giving it. The policy included the 5 rights and recommended triple-checking them.
A resident had visibly broken and discolored upper teeth and reported not seeing a dentist in over 2 years. Record review showed only one dental consult was available, while the DON stated the facility has a monthly dental hygienist and refers residents to a dentist when issues arise. The resident’s dental consult documented fractured teeth, but no additional dental service records were provided during survey review.
The facility failed to discard a green salad stored in the refrigerator past its 'used by' date, as observed during a tour. The Dietary Manager acknowledged the oversight, which violated the facility's policy requiring expired food to be discarded. This lapse in food storage practices could potentially affect 65 residents receiving meals from the kitchen.
A facility failed to maintain privacy for a resident during a medical procedure when an LPN was observed obtaining a blood glucose reading and administering insulin with the room door open. The resident, with Type 2 Diabetes Mellitus, was receiving insulin as per a medication order. The LPN admitted the oversight, and the DON confirmed the expectation of privacy during care. The facility's policy emphasizes residents' rights to privacy and confidentiality.
A hospice resident's change in condition was not documented by an LPN, who believed hospice managed the care and documentation. The DON expects documentation for all residents, including hospice patients. The resident, with multiple diagnoses, expired in the facility. The facility's policy requires timely and complete documentation, which was not followed.
The facility failed to have a treatment order in place and perform dressing changes to a resident's sacral wound for seven days, resulting in the wound deteriorating and the resident being diagnosed with osteomyelitis. Despite receiving IV antibiotics, the resident ultimately passed away due to pneumonia and osteomyelitis.
Water Not Available at Bedside for Residents With Thin Liquid Orders
Penalty
Summary
The facility failed to make water available for residents between meals and failed to make water pitchers available at the bedside for residents who had thin liquid orders. During observation on the units, several residents, including R2, R9, R10, R11, and R12, were seen without water or water pitchers at the bedside, and other residents were observed with empty water pitchers. When asked why residents did not have water pitchers or water available before lunch, a CNA stated that residents get water on their trays during mealtimes and later said residents should be given water in the pitchers daily, but she was not sure whether new pitchers were available in storage. The DON stated that residents with orders for thin liquids should have water available at the bedside unless they were on fluid restriction. The DON then identified residents on nectar thick liquids, honey thick liquids, and fluid restriction, and the five residents observed without water were not on those lists. Physician order sheets showed that R2, R9, R10, R11, and R12 all had orders for thin liquids, and their nutrition care plans stated that diet orders should be followed. The facility policy on water pass hydration states that water is to be provided to residents in a clean and sanitary manner to meet hydration needs.
Nonfunctional Bed Frames and Electric Bed Not in Good Repair
Penalty
Summary
The facility failed to ensure that residents' bed frames had functioning manual lift mechanisms to raise or lower the bed and failed to ensure that a resident's electric bed was in good repair. During observation with CNA staff, R7's electric bed frame control was not functioning; the CNA looked under the mattress, found the electric cord, and tried to connect it to the bed frame, but the bed still did not work. The CNA stated she would notify Maintenance staff. During the same observation, several other bed frames with manual crank handles, including those for R3, R4, R5, and R6, were observed not to work properly. A CNA stated that if the crank handle cannot lift the bed, staff must bend too much to help residents who need assistance. The Maintenance Director stated that some bed frames had been repaired after nursing staff notified him, that some crank handles had rusted ends, and that he used oil spray to make stiff crank handles work properly. The Administrator stated the facility had started purchasing more electric beds and would continue replacing old bed frames with new beds.
Failure to Ensure Staff Wore Visible Identification Badges
Penalty
Summary
The facility failed to ensure that staff members consistently wore visible identification badges that disclosed their first name, licensure status, and staff position, as required by the Medical Patient Rights Act. During observations and interviews, multiple staff members were found either not wearing ID badges or wearing badges that did not display the required information. For example, an LPN was observed with an ID badge that did not visibly display their name and staff position until it was adjusted during the survey. Several CNAs and a restorative aide were observed without any ID badges, with some stating they had never received a badge or had lost theirs and were waiting for replacements. Interviews with cognitively intact residents revealed concerns about the lack of visible staff identification. Residents expressed discomfort and uncertainty about the identity of individuals providing care, with some stating they did not know who was entering their rooms or asking them to sign documents. Residents indicated that the absence of proper identification made them feel vulnerable and unable to verify if the person was a legitimate staff member. Further review showed that the facility did not have a clear policy regarding employee ID badges, and leadership was unaware of any such policy in place. While the facility used different colored scrubs to differentiate job positions and had stickers available for temporary identification, these measures were not consistently implemented. The deficiency was identified as having the potential to affect all residents on the unit, as staff assigned to the unit were not in compliance with the identification requirements.
Insufficient Nursing Staffing With Delayed Care, Medication Errors, and Missed Restorative Services
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of dependent residents, and the report documents multiple observations showing delayed or incomplete care during the survey. On 7/21/25, surveyors observed R6 with long facial hair and notably thick, long toenails; R6 stated he was supposed to have daily shaves. An LPN acknowledged the long toenails and said he could use a good clipping. The same resident also had a low air loss mattress set to the incorrect weight. Surveyors also observed R2 with a low air loss mattress on incorrect settings, and R4 with long nails and black debris beneath them, difficulty with self-care due to hemiplegia and hemiparesis, and a low air loss mattress on the incorrect setting while in use. Additional care concerns were identified with R4’s treatment and catheter care. R4’s IVPB label indicated 250/83 ml/hr, but the rate was set at 250 ml/hr, and an RN confirmed the intended rate was 83 ml/hr. R4’s indwelling urinary catheter contained cranberry-colored urine, which the RN described as red and blood-tinged; the RN stated the resident was on Eliquis and Plavix and that the nurse practitioner had suggested the blood could be related to tension or blood thinners. Surveyors observed that the catheter was not secured to the resident’s leg, and there was notable tension from the bag placement and unsecured tubing. The report also describes missed or incomplete restorative care and delayed medication administration affecting multiple residents. R67 had contracted hands and arm, a deformed and internally rotated left foot, and stated that therapy was not being done as expected; restorative devices were not in use, and the restorative aide stated the resident did not have hand splints and that PROM had been discontinued. R44 had difficulty moving his lower extremities, yet the restorative documentation showed missing entries for several days. During medication pass observations, surveyors found a 24% medication error rate, with several residents not receiving scheduled 9 a.m. medications within the required window; multiple nurses had large numbers of residents still highlighted red on the EMAR, indicating they were behind. The administrator stated the facility did not have a staffing policy and staffing was based on resident acuity and population.
Improper Labeling and Storage of Medications
Penalty
Summary
Drugs and biologicals were not consistently labeled or secured in accordance with facility policy and accepted storage practices. On 7/21/25, an IVPB infusing through a resident’s IV access did not have the resident’s name on the bag, and the listed supplements on the IVPB label had check boxes next to vitamin C, B complex, B7, zinc, and amino blend, but none were checked. When the RN was asked what medications were in the IVPB, she stated, "We don't," and said she did not hang the IVPB. The facility census was 87 residents at the time of the findings. Medication storage problems were also observed in both unit medication rooms. In unit 1, refrigerated medications including insulin and Ativan solution were found on top of a refrigerator labeled for food, while a thermometer in a locked box containing Ativan solution read 79F. The refrigerator temperature log showed repeated entries of "Ice" on multiple July dates. In unit 2, the medication room was unlocked and unsupervised when observed, the refrigerator temperature was 67F, and there was about 3 inches of ice buildup in the freezer. The temperature log for unit 2 also documented repeated "Ice" entries, and the 7/23 temperature entry was blank. The DON stated the refrigerator should be 36F to 46F and identified refrigerated medications in the unit 2 refrigerator including insulins, olanzepine solution, haldol decanoate, zepbound, latanoprost, and aplisol.
Outside Dumpster Left Open
Penalty
Summary
The facility failed to ensure that the outside dumpster was kept closed. On 7/21/2025 at 9:39am, the outside facility dumpster was observed with the Dietary Manager and was open at the outside dumpster area, with a swarm of flies flying inside and outside the dumpster. When asked about the opened dumpster, the Dietary Manager stated that it should be kept closed to stop rodents and bugs and noted that housekeeping was also dumping items there. On 7/22/2025 at 9:57am, the outside facility dumpster was again observed open with the Housekeeping Director/Head of Laundry present, and a swarm of flies was seen flying inside and outside the dumpster. When asked about the opened dumpster, the Housekeeping Director/Head of Laundry stated that the dumpster should be kept closed at all times to keep the smell and flies down and said that Housekeeping and Dietary use the dumpster. The facility census documented 87 residents residing at the facility. Facility policy stated that outside dumpsters shall have lids that can be tightly closed and that the lid shall be kept closed.
Failure to Provide Grooming and Nail Care
Penalty
Summary
The facility failed to provide ADL care, including grooming and nail care, for dependent residents. R6, who had arthritis, lack of coordination, and severe cognitive impairment with a BIMS score of 4, was documented as dependent on staff for personal hygiene and had a care plan reflecting that dependence. On 7/21/25, R6 was observed with long facial hair and notably thick, long toenails. When asked, R6 stated he was supposed to have shaves every day, and an LPN acknowledged the long toenails and said he could use a good clipping. The same interaction showed the resident did not wear a beard, despite the facial hair observed. R4, who had hemiplegia and hemiparesis following cerebral infarction and moderate cognitive impairment, was assessed as requiring substantial to maximal assistance with personal hygiene, and the care plan directed staff to monitor ADL abilities and assist as needed. On 7/21/25, R4 was observed with long nails and black debris beneath them, and R4 stated he could not cut or clean his own nails. R3, who had Parkinson's disease, arthritis, rheumatoid arthritis, and a BIMS score of 15 indicating intact cognition, was observed with long fingernails and brown substances under and along the sides of all 10 fingernails. R3 stated the nails were filthy and that she asked all the time for help. The facility's ADL and nail care policies required grooming and nail care, including observing nail condition during bathing and cleaning debris from around and under the nails, but the report also identified R59 as a dependent resident in the sample without further detail in the excerpt provided.
IVPB Infusion Rate and Medication Timing Errors
Penalty
Summary
The facility failed to ensure that R4's IVPB was infusing at the correct rate. On 7/21/25 at 11:16am, R4 had a 250 milliliter IVPB infusing through IV access, and the IVPB label stated 250/83 ml/hr, but the rate was set at 250 ml/hr. When the surveyor asked about the rate, V11, RN, inspected the dial-a-flow and stated it was set at 250 even though it was supposed to be 83 ml/hr. The facility also failed to ensure that prescribed medications were administered within the required time frame for 32 of 40 residents in the sample. On 7/22/25, multiple assigned residents were highlighted red on the EMAR, and staff acknowledged that the residents had not yet received their 9am medications. V8, an LPN, stated red meant being behind in time and confirmed the medications had not been given yet; V11, RN, stated the highlighted residents had not yet received their 9am medications; and V20, LPN, stated that red meant late and that the assigned residents had not received their 9am medications. The facility medication administration policy stated medications are to be administered in accordance with prescriber orders and within 1 hour before or after the scheduled time unless otherwise specified.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to conduct hand hygiene before passing meal trays and before providing meal-time assistance. During observation, a CNA performed hand hygiene, retrieved a meal tray, and served it to one resident while touching the resident to arrange the tray. The CNA then returned to the food cart, did not perform hand hygiene, retrieved and served additional meal trays to three other residents, again without hand hygiene between residents. The residents involved in this observation were R22, R72, R76, and R12. A restorative aide was also observed placing dirty meal trays into the food cart for return to the kitchen and then, without performing hand hygiene, going to R22’s table, asking if the resident was done eating, and picking up the resident’s spoon to assist with eating. The DON/IP stated that hand hygiene is done while passing trays to prevent transferring bacteria to other residents. Facility policy required hand hygiene before and after direct contact with a patient’s intact skin and after contact with inanimate objects in the immediate vicinity of the patient, and required all personnel to routinely wash hands and use appropriate barrier precautions.
Failure to Refer Residents for PASRR Level II Review
Penalty
Summary
The facility failed to refer residents with possible serious mental disorders for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This deficiency affected 2 residents, R5 and R79, who were reviewed for pre-admission screening in a sample of 54 residents. The report states that the facility participates in the Preadmission Screening and Resident Review (PASRR) Level 1 screening process for all new admissions and readmissions to determine whether an individual meets criteria for mental disorder, intellectual disability, or a related condition. R79 was [AGE] years old and admitted to the facility on [DATE]. The resident’s medical history included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes, essential primary hypertension, neuralgia, neuritis unspecified, major depressive disorder severe without psychotic features, and schizoaffective disorder bipolar type. The facility policy stated that residents with newly evident or possible serious mental disorder, intellectual disability, or related condition are to be referred for a level II review upon a significant change in status assessment to the State PASARR representative, but the report indicates this referral was not made for the affected residents.
Failure to Develop Pain Management Care Plans
Penalty
Summary
The facility failed to develop and implement pain management care plans with measurable resident goals and preferences for two residents who received pain medications, R20 and R59. The deficiency was identified during interview and record review of a sample of 54 residents. The facility’s comprehensive care plan policy stated that care plans should include measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. R59, who had a history including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, diabetic neuropathy, right below-knee amputation, weakness, and major depressive disorder, was observed awake and alert and stated he was waiting for someone to change him. He reported that the nurses had run out of his Norco, that he had received one tablet the day before and was told it was the last one, and that he was in pain rated 8 out of 10. He stated Tylenol did not help, that he had a stroke and could not move his right side, and that he did not want to sit up because of pain. His record showed orders for pain assessment every shift and active pain medications, including hydrocodone-acetaminophen, acetaminophen, and a lidocaine patch, but his care plan did not include measurable goals or interventions to manage pain. R20, who had diagnoses including major depressive disorder, type 2 diabetes with hyperglycemia, unspecified psychosis, hyperlipidemia, and hypotension, stated he had pain sometimes and received medication when needed. His record showed an order to assess pain every shift and an active ibuprofen order for mild pain, but he did not have a pain management care plan.
Improper LALM settings and use for residents with pressure ulcers
Penalty
Summary
The facility failed to ensure it had a Low Air Loss Mattress (LALM) policy, failed to ensure staff were aware of required LALM settings, failed to ensure the settings were correct, and failed to ensure the LALM was used correctly for three residents with pressure ulcers. R6 had a diagnosis of pressure ulcer of the left heel and was observed lying on a LALM while wearing an incontinence brief, with a flat sheet and thick pad beneath him; the mattress was set at 210 pounds even though his weight on 7/6/25 was 120.6 pounds. When asked about the resident’s weight and the mattress setting, an LPN stated the resident weighed about 160 pounds and confirmed the mattress was set at 210. The LPN also stated that only a pad and a sheet were supposed to be on the mattress while in use. R2 had diagnoses including pressure ulcer of the left buttock, unstageable, and was observed with MASD on the left buttock while lying on a LALM set at 280 pounds in static mode. An LPN stated the mattress was on static and did not know what static mode indicated; the roommate stated the resident did not weigh 280 pounds. R2’s weight on 7/6/25 was 179.2 pounds. R4 had a diagnosis of pressure ulcer of the left lower back, stage 3, and was observed lying on a LALM set at 350 pounds even though he did not appear to weigh that much; his 7/6/25 weight was 217 pounds. The Administrator later stated the facility did not have a policy for low air loss mattresses and relied on the manufacturer’s guidelines, and stated that a flat sheet with a disposable brief or a flat sheet with a pad was allowed on a LALM.
Failure to Assess and Provide Restorative Care and Devices
Penalty
Summary
The facility failed to ensure that residents were properly assessed for restorative care needs and restorative device needs, and failed to provide required restorative care and devices to two residents. One resident with MS had documentation indicating PROM exercises to all extremities twice daily, but several entries were blank. The resident’s name was not included on the facility list of residents with orthotics or splints, and when observed the resident had contracted bilateral hands and a contracted right arm, with no restorative devices in use. The resident stated that the feet had become bent because they were never stretched and said restorative therapy was not being done as claimed. The resident’s left foot was internally rotated and notably deformed. A second resident with dementia and osteoarthritis of the hip had documentation for daily AROM exercises, but the resident’s name was not included on the July restorative intervention/task schedule report. When observed, the resident was seated in a wheelchair and had difficulty lifting the left foot and was unable to lift the right foot. Staff interviews showed uncertainty about who was on the restorative list, and the restorative aide and restorative nurse reported missing or blank documentation entries for both residents’ restorative care. The restorative aide also stated that PROM for the first resident had been discontinued and that restorative care was sometimes not completed because staff were sent out to escorting duties.
Failure to Secure Indwelling Urinary Catheter and Follow Care Plan
Penalty
Summary
The facility failed to implement required care plan interventions and failed to provide a urinary catheter leg strap to prevent tension and trauma for a resident with an indwelling urinary catheter. The resident had diagnoses including hydronephrosis with renal and ureteral calculous obstruction, and physician orders dated 5/2/25 required indwelling urinary catheter care every shift. The care plan also directed staff to monitor for blood-tinged urine. During observation on 7/21/25, the resident’s catheter urine was cranberry colored, and the RN stated it was red and appeared dark red with blood. The RN reported the resident had blood-tinged urine at times and was taking Eliquis and Plavix, and said the Nurse Practitioner had indicated it could be from tension or blood thinners. When asked whether the catheter was secured to the resident’s leg to prevent tension or trauma, the RN stated it was not. Surveyor inspection found notable tension on the catheter due to bag placement and failure to secure the tubing to the resident’s leg. The facility’s urinary catheter care policy states indwelling catheters may be secured to prevent trauma and tension.
Enteral Feeding Order and Administration Deficiencies
Penalty
Summary
The facility failed to follow physician orders and failed to ensure that enteral feed orders included the required total volume with start and stop times for a resident with a gastrostomy tube. R6 had physician orders dated 6/13/25 for nothing by mouth and 6/27/25 for Jevity 1.5 cal at 45 ml per hour for 20 hours, but the order did not include the total volume or start/stop times. The July 2025 MAR showed a 1:00 pm start time, but no stop time. On 7/21/25, the surveyor observed the resident's Jevity 1.5 cal tube feeding hung at 1:00 pm from the prior day at 45 ml per hour, and it was not infusing at the time of observation. During interview, the LPN stated the feeding goes back up at 1:00 pm and that she discontinues it at 9:00 am. When asked how much remained in the 1,000 ml container, she estimated about 350 ml, indicating the resident had received about 650 ml. Based on the ordered rate and duration, 900 ml should have been infused, meaning the resident did not receive 250 ml of the prescribed enteral feeding. The DON stated that tube feeding orders should include the amount, formula, and how long the hours are. The resident's weights were 125.8 pounds on 6/13/25 and 120.6 pounds on 7/6/25, a 4.13% weight loss over roughly 3 weeks. The facility's gastrostomy tube feeding policy states the prescribed formula volume is given continuously over 16 to 24 hours and that the licensed nurse will review the physician's order for type of formula, concentration, rate of flow, and method of administration.
Respiratory equipment not dated, labeled, or contained
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident, R7, when the facility failed to ensure the oxygen humidifier was changed weekly, failed to date and label the nasal cannula, and failed to contain respiratory equipment when not in use. On 7/21/2025 at 10:28 AM, R7’s nasal cannula oxygen tubing that was not currently in use was observed hanging over the oxygen concentrator, not labeled and not contained. At the same time, R7’s oxygen humidifier was observed dated 7/7/25, which was 14 days earlier. R7’s CPAP mask was also observed not contained and laying on top of R7’s white storage bin. R7’s record documented diagnoses including asthma, sleep apnea, acute and chronic respiratory failure, and pneumonia. R7’s BIMS score was 15, indicating cognitive intactness. The order summary directed staff to rinse the CPAP/BiPAP water reservoir, dry it thoroughly, refill with distilled or sterile water before daily use, and to change, date, and label all oxygen tubing, bags, and set-ups; it also ordered oxygen at 2 LPM as needed and to maintain saturations above 90%. The care plan documented altered respiratory status/difficulty breathing related to sleep apnea, obesity, and OSA, with oxygen as ordered and oxygen saturation checks every shift, and another care plan noted use of a CPAP/BiPAP machine while sleeping.
Unavailable Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident and failed to ensure prescribed medications were available. R12’s July 2025 physician order sheets included Citalopram 20 mg daily, Mirtazapine 7.5 mg daily, and Oxybutynin Chloride ER 5 mg daily, scheduled for 9:00 a.m. administration. On 7/22 at 8:34 a.m., while dispensing the resident’s scheduled medications, an LPN stated that all three medications were unavailable and said, “I don't have it.” When asked whether the medications had been reordered, the LPN reviewed the EMAR and stated that on 7/19/25 the pharmacy indicated the order had been rejected and the patient status was leave of absence for each unavailable medication. The LPN also stated the facility had additional medications in electronic medication storage, and the DON searched for the medications. At 9:01 a.m., the surveyor asked whether the medications were found in electronic medication storage, and the DON stated they were not there. The DON also stated there was no list of medications contained in the facility electronic medication storage. The facility policy stated medications are to be received from the pharmacy on a timely basis and reordered at least 3 days in advance to ensure adequate supply is on hand.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 6 medication errors out of 25 opportunities for a 24% error rate. Survey observation, interview, and record review showed that prescribed medications were not available for one resident, an extended-release medication was crushed for another resident, and a prescribed dose was not correctly dispensed for a third resident. Three of four residents in the medication administration sample were affected. For one resident, the July 2025 POS included Citalopram 20 mg daily, Mirtazapine 7.5 mg daily, and Oxybutynin Chloride ER 5 mg daily for 9:00 a.m. administration, but at 8:34 a.m. the LPN stated the three medications were unavailable, and the DON later stated the medications were not in the facility electronic medication storage. For another resident, the POS ordered Lisinopril 10 mg with 40 mg to be given in the morning, but at 9:08 a.m. only one 10 mg tablet was dispensed and the LPN stated that four tablets were needed. For a third resident, the RN dispensed Oxybutynin Chloride ER and crushed the tablet before administration, and stated that ER meant extended release and that staff are not allowed to crush extended-release medications.
Medication Administration Errors Involving Unavailable, Underdosed, and Crushed Medications
Penalty
Summary
The facility failed to follow its medication administration policy and failed to ensure residents were free from significant medication errors for three of four residents reviewed for medication. For R12, the July 2025 physician order sheet included Citalopram, Mirtazapine, and Oxybutynin Chloride scheduled for 9:00 a.m. administration, but at 8:34 a.m. on 7/22/25 an LPN stated that all three medications were unavailable. The LPN said the facility had additional medications in the electronic medication storage, and the DON was searching for R12’s unavailable medications. At 9:01 a.m., when asked whether the medications were found in the electronic medication storage, the DON stated that she looked up all the meds and they were not there. For R96, the July 2025 physician order sheet directed Lisinopril 10 mg, give 40 mg in the morning, but at 9:08 a.m. on 7/22/25 an LPN dispensed the medication and only one 10 mg tablet was prepared. When asked about the order, the LPN reviewed the EMAR and stated, "Give 40 milligrams, we need more pills," and acknowledged that four tablets should have been dispensed. For R80, at 9:20 a.m. on 7/22/25 an LPN dispensed Oxybutynin Chloride ER and crushed the tablet before administration. When asked what ER meant, the LPN stated it meant extended release and said she did not think staff are allowed to crush extended-release medications. The facility’s undated medication administration policy included the 5 rights and recommended triple checking those rights.
Failure to Provide Dental Follow-Up for Fractured Teeth
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident with abnormal teeth findings. During observation, R67’s upper teeth were noted to be broken and discolored, and the resident stated they had not seen a dentist in over 2 years. Record review showed the facility could provide only one dental consult dated 4/20/24, and the dental service log was not provided during the survey. The Director of Nursing stated the facility has a dental hygienist who comes monthly and refers residents to a dentist if there is an issue, and the resident’s 4/20/25 dental consult documented a mix of fully intact and fractured teeth, indicating fractured teeth had already been identified. The facility’s oral-dental assessment policy states that obvious abnormalities of the teeth and gums require referral to a dentist and notification of Social Service if a dental referral is needed.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure proper food storage practices, which could potentially lead to foodborne illness among the 65 residents receiving food from the kitchen. During an initial tour, a green salad was observed in a transparent container in the refrigerator, labeled with a 'used by' date that had already passed. The Dietary Manager acknowledged that the salad should have been discarded since the 'used by' date was the previous day and proceeded to remove the label. The facility's policy requires that food items be labeled with the name and expiration date, and any food past its expiration date should be discarded. However, this procedure was not followed, as evidenced by the expired salad still being stored in the refrigerator.
Failure to Maintain Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to maintain privacy for a resident during a medical procedure. On September 5, 2024, at noon, an LPN was observed obtaining a blood glucose reading and administering insulin to a resident with the room door open to the hallway, compromising the resident's privacy. The resident, identified as having Type 2 Diabetes Mellitus without complications, was receiving insulin lispro on a sliding scale three times a day as per a medication order dated May 17, 2023. The LPN acknowledged the oversight, stating that the curtain should have been pulled or the door closed. The Director of Nursing confirmed that all nurses are expected to provide privacy when administering care. The facility's policy on residents' rights, dated August 23, 2017, emphasizes the right to privacy and confidentiality, which was not upheld in this instance.
Failure to Document Change in Condition for Hospice Resident
Penalty
Summary
The facility failed to document a significant change in condition for a hospice resident, identified as R85, who was part of a sample of 18 residents reviewed. The deficiency was identified during a review of R85's closed record following her death. It was found that there was no documentation in the nurses' notes regarding a change in R85's condition. The Licensed Practical Nurse (LPN), identified as V10, who was responsible for R85 on the night of her death, stated that she did not document the change in condition because she believed that hospice managed the care and documentation for hospice patients. V10 only documented the presumed death note. The Director of Nursing (DON), identified as V2, stated that she expects her staff to document on all residents, including those under hospice care. R85 was a [AGE] year-old female with diagnoses including encephalopathy, altered mental status, insomnia, and essential hypertension. She was admitted to the facility on a specified date and expired there. The facility's Electronic Health Record policy requires that entries be timely, accurate, relevant, and complete, which was not adhered to in this case.
Failure to Provide Timely Wound Care Leads to Osteomyelitis and Resident Death
Penalty
Summary
The facility failed to have a treatment order in place and failed to perform dressing changes to a resident's sacral wound for seven days. This resulted in the sacral wound deteriorating, becoming larger in size, and the resident being diagnosed with osteomyelitis of the sacral wound after being hospitalized for an elevated white blood cell count indicating an infection. The resident, who had multiple diagnoses including adult failure to thrive, dementia, cerebral infarction, type 2 diabetes, and several pressure ulcers, was admitted to the facility with a stage 2 pressure ulcer on the sacrum, which later progressed to a stage 4 ulcer with necrotic tissue extending to the bone. Upon admission, the resident had multiple skin issues, including a pressure ulcer to the coccyx, right buttocks, right and left heels, right clavicle, and right ear. The physician and the Director of Nursing (DON) were made aware of the admission. However, there was no dressing change order for the sacral wound until a week later, and the zinc barrier cream order was not started until four days after admission. The lack of timely and appropriate wound care led to the sacral wound deteriorating and becoming infected, ultimately resulting in osteomyelitis. Interviews with the wound nurse, admitting nurse, and DON revealed that there was a lack of awareness and communication regarding the resident's wound care needs. The wound nurse and admitting nurse could not recall the stage of the sacral wound upon admission or the specific orders for wound care. The DON acknowledged that an order for dressing changes should have been put in place within 24 hours of admission and that the failure to do so likely contributed to the wound's deterioration and subsequent infection. The resident's condition continued to decline, and despite receiving IV antibiotics, the resident ultimately passed away due to pneumonia and osteomyelitis.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,677 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Midlothian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heather Health Care Center | 2.4 mi | ★★★★★ | 19 | 1 |
| Thryve Of Crestwood | 2.8 mi | ★★★★★ | 2 | 0 |
| Crestwood Terrace | 3 mi | ★★★★★ | 2 | 0 |
| Aliya Of Crestwood | 3.4 mi | ★★★★★ | 5 | 0 |
| Pine Crest Health Care | 3.8 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.