Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Midlothian Healthcare Center during CMS and state inspections, most recent first.
Two residents experienced lapses in infection control when staff did not follow PPE and hand hygiene protocols during wound care and peri-care. One resident with a stage 4 heel pressure ulcer and a suprapubic catheter, on enhanced barrier precautions, received wound care from an LVN who failed to wear a gown as required by the facility’s infection control policy for high-contact care. Another resident with diabetes, neuropathic bladder, frequent incontinence, and recurrent UTIs received peri-care from a CNA who did not perform hand hygiene between glove changes and touched bedding and clothing after glove removal without sanitizing hands. Staff interviews confirmed prior training on EBP, PPE, and hand hygiene, but revealed gaps in understanding and implementation, while leadership interviews and policy review showed expectations for gown and glove use under enhanced barrier precautions and for hand sanitizing between glove changes, although the written peri-care/hand washing policy lacked specific glove and interim hand hygiene steps.
A resident with severe cognitive impairment and multiple comorbidities was found on the floor by an LVN, who did not recognize the incident as a fall and failed to notify the physician or responsible party. The resident later exhibited pain and was found to have a fracture, but the family and physician were only informed about the pain and new orders, not the fall itself. Facility leadership confirmed that required notifications and documentation were not completed as per policy.
A resident was mistakenly administered Morphine 100mg instead of the prescribed 10mg due to a pharmacy entry error and oversight by a CMA. The resident, with a complex medical history, was hospitalized for acute respiratory distress. The facility's DON monitored the resident but did not administer Narcan or send the resident to the ED immediately, despite signs of sleepiness and sweating. The error was acknowledged by the staff, and the CMA expressed remorse.
A resident with a complex medical history was mistakenly administered Morphine 100mg ER instead of the prescribed 10mg ER due to a pharmacy order entry error. The facility's CMA failed to verify the correct dosage before administration. Although the resident showed no immediate signs of distress, they were later hospitalized in the ICU for an accidental overdose, experiencing somnolence and hypoxemia.
The facility failed to maintain an effective infection control program, as expired and contaminated medical supplies were found in the medication storage room and on a medication cart. Staff interviews revealed a lack of consistent adherence to the policy requiring the removal and disposal of such items, posing risks of infection and ineffective treatment.
The facility failed to serve the posted lunch and dinner menus to two residents, leading to a deficiency in meeting their nutritional needs. The Dietary Manager changed the menu without documenting the changes, and the residents were unable to see the posted menus due to their height and location.
The facility failed to maintain food safety standards, as the Dietary Aide did not wear proper hair and beard restraints, and expired food items were not discarded. Additionally, a lunchbox in the nourishment room refrigerator lacked proper labeling. These actions violated the facility's policies and the Texas Food Establishment Rules, potentially risking residents' health.
A resident with severe cognitive impairment and mobility issues was not fed her lunch in a timely manner, as observed during a dining room lunch tray pass. The resident, who required assistance with meals, was left unattended for about 10 minutes before the ADON began assisting her, while other residents received feeding assistance promptly.
Failure to Follow PPE and Hand Hygiene Protocols During Wound Care and Peri-Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices for two residents during observed care. For one resident, a female with hemiplegia, hypotension, dementia, and a stage 4 pressure ulcer on the left heel, the care plan and orders documented that she was on enhanced barrier precautions for a suprapubic catheter and heel wound, and that wound care required daily dressing changes. During an observation of wound care, the LVN performed the procedure without donning a gown, despite the facility’s infection control policy requiring gown and gloves for high-contact resident care activities under enhanced barrier precautions. In an interview, the LVN acknowledged having been trained on evidence-based practice (EBP) protocols about a month earlier, stated that nurses were responsible for following the EBP policy, and admitted she forgot to wear a gown and understood that not following EBP could lead to cross contamination and passing infection to other residents. For the second resident, a 78-year-old female with type 2 diabetes mellitus, repeated falls, neuropathic bladder, frequent urinary incontinence, and a history of recurrent UTIs treated with prophylactic antibiotics, staff were responsible per the care plan for checking for incontinence and washing, rinsing, and drying soiled areas. During an observation of peri-care, CNA A did not perform hand hygiene between glove changes while cleaning the resident’s front perineal area and before moving to the back (anal) area. After removing his gloves, CNA A touched the resident’s bedding and clothing while assisting with repositioning without sanitizing his hands. CNA B assisted by handing wipes during the peri-care. In interviews, CNA A reported receiving in-service training on hand hygiene and peri-care about a month earlier but stated he was not aware of the need to sanitize hands between glove changes during peri-care and believed washing before and after the procedure was sufficient; he acknowledged that improper hand hygiene could cause cross contamination. CNA B stated she had received similar training a few months earlier and had been instructed to sanitize hands between glove changes during peri-care. The ADON, serving as Infection Preventionist, the DON, and the Administrator all stated that staff were trained to wear gowns and gloves for high-contact care under enhanced barrier precautions and to sanitize hands between glove changes during peri-care, and that they were responsible for monitoring staff compliance. Review of the facility’s peri-care and hand washing policy indicated it addressed hand cleansing to prevent transmission of infectious material but did not specify glove use or hand sanitizing between glove changes, while the infection control policy on enhanced barrier protection required gown and gloves during high-contact resident care activities for residents with wounds and indwelling devices.
Failure to Notify Physician and Family of Resident Fall and Injury
Penalty
Summary
The facility failed to immediately notify a resident's representative and physician of a significant change in the resident's condition following a fall. The resident, an elderly male with severe cognitive impairment, dementia, diabetes, hypertension, end stage renal disease, lack of coordination, and neuropathy, was found on the floor after midnight by an LVN. The LVN did not report the incident as a fall, did not notify the responsible party (RP) or physician, and did not complete the required documentation or incident report at that time. The LVN assumed the resident had simply slipped out of bed and did not consider it a fall since the resident denied falling and was not complaining of pain at that moment. Later in the day, the resident was noted to be non-compliant with therapy and was assessed for pain and a bulging area on the right side. The physician was contacted in the afternoon regarding the resident's pain, and an x-ray was ordered, which later revealed a fracture. The RP was notified only about the new orders and the need for an x-ray, but was not informed about the fall itself. The physician was also not informed that the resident had fallen, only that he was experiencing pain. The RP only learned about the fall incident much later, after another family member visited the facility. Interviews with facility leadership, including the Administrator and DON, confirmed that their expectation was for staff to report all falls, complete assessments, document findings, and notify the appropriate parties, including the physician and family. The LVN involved admitted to not notifying the RP or physician and not recognizing the incident as a fall. The facility's policy requires immediate notification of accidents resulting in injury or significant changes in condition, but this protocol was not followed in this case.
Medication Administration Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in the administration of an incorrect dosage of Morphine. The resident was supposed to receive Morphine 10mg ER as per the physician's order, but instead, was administered Morphine 100mg. This error was attributed to a pharmacy entry mistake, which was not caught by the reviewing pharmacist, and subsequently, the medication was dispensed and administered by a Certified Medication Aide (CMA) without noticing the discrepancy. The resident, who had a complex medical history including dementia, fibromyalgia, and chronic kidney disease, was admitted to the hospital with acute respiratory distress following the overdose. The Director of Nursing (DON) was informed of the pharmacy error and took steps to monitor the resident's vital signs. Despite the resident showing signs of sleepiness and sweating, the DON did not find it necessary to administer Narcan or send the resident to the emergency department immediately. The resident's Responsible Representative (RR) insisted on hospital transfer, which was eventually carried out. Interviews with facility staff, including the DON, Administrator, and the CMA, revealed that the error was acknowledged, and the CMA expressed remorse for not catching the mistake. The facility's policy required medication administration to be in accordance with physician orders, and the CMA admitted to not verifying the medication label against the Medication Administration Record (MAR) thoroughly. The facility's personnel records indicated that the CMA had no prior disciplinary actions, and the incident was considered an unfortunate mistake by the staff.
Significant Medication Error Due to Incorrect Morphine Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the administration of an incorrect dosage of Morphine. The resident, who had a complex medical history including dementia, fibromyalgia, and chronic kidney disease, was prescribed Morphine 10mg ER but was mistakenly given Morphine 100mg ER. This error was attributed to a pharmacy order entry mistake, which was not caught by the pharmacy staff or the facility's CMA who administered the medication. The error was discovered when the pharmacy contacted the facility to confirm the order, and it was found that the wrong dosage had been administered. The resident was monitored for adverse effects, and although the facility's staff reported no immediate signs of respiratory distress, the resident was later admitted to the hospital's ICU due to an accidental overdose. The resident experienced symptoms such as somnolence and hypoxemia, requiring oxygen support. Interviews with facility staff, including the DON and the CMA, revealed that the CMA did not notice the discrepancy between the prescribed and administered dosages. The facility's policy required medication to be administered according to the physician's written orders, and the CMA admitted to failing to verify the correct dosage before administration. The incident highlighted a breakdown in the medication administration process, leading to the resident's hospitalization.
Infection Control Deficiency Due to Expired Medical Supplies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the presence of expired and contaminated medical supplies in the medication storage room and on a medication cart near the 800 Hall. During an observation, a blood collection set was found expired, a sterile irrigation tray was opened and no longer sterile, and a pack of gauze was stored uncovered. Additionally, expired syringes were found on the medication cart. These findings indicate a lapse in the facility's procedures for managing medical supplies, which could potentially lead to infection, ineffective treatment, and harm to residents. Interviews with staff, including a medication aide (MA), a licensed vocational nurse (LVN), the administrator (ADM), and the director of nursing (DON), revealed that the facility's policy required expired or opened sterile supplies to be discarded. However, the responsibility for checking and removing such items was not consistently executed. Staff acknowledged the potential negative outcomes of using expired or opened items, such as infection, reduced effectiveness, or even poisoning. The facility's policy, revised in July 2023, mandates the immediate removal and proper disposal of outdated or contaminated medications, but this was not adhered to, leading to the identified deficiencies.
Failure to Follow and Document Menu Changes
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents and were followed as planned. Specifically, on 12/01/2024, the facility did not serve the posted lunch and dinner menus to two residents, which could place them at risk of poor intake, chemical imbalance, and/or weight loss. Resident #7, a female with moderate cognitive impairment and impaired vision, was not served the posted menu items. Similarly, Resident #30, a male with intact cognition but impaired vision, also did not receive the meals as per the posted menu. Both residents were unable to see the posted menus due to their height and location. The Dietary Manager (DM) admitted to changing the menu on 12/01/2024 because she felt the posted dinner sounded better as a lunch meal. However, she did not document these changes in the substitution logs for November or December. The facility's policy requires that any meal served that varies from the planned menu should be noted on a log in the kitchen. The DM's failure to adhere to this policy and the lack of accessible menu information for residents contributed to the deficiency.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen and nourishment room. Observations revealed that the Dietary Aide (DA) did not wear effective hair and beard restraints while in the kitchen, which is against the facility's infection control policy. The DA admitted to not consistently using a beard restraint, despite knowing the policy. Additionally, expired food items, including instant oatmeal packets, vegetable juice blend cans, pure corn starch, and Vitamin D milk, were found in the kitchen pantry and refrigerator, indicating a failure to discard expired items as per the Texas Food Establishment Rules (TFER). In the nourishment room, a refrigerator contained a lunchbox without a name or date, contrary to the facility's policy requiring all items to be labeled with the resident's name and date. Interviews with the Registered Dietitian (RD) and Administrator (ADM) confirmed that the facility's practices should align with TFER guidelines, which were not followed in these instances. These deficiencies could potentially place residents at risk for health complications and foodborne illnesses.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically in ensuring timely feeding during lunch. The resident, a female with severe cognitive impairment and mobility issues due to conditions such as senile degeneration of the brain, dementia, and discitis, required supervision or assistance with eating. Her care plan indicated she was unable to handle hot liquids and needed help with meals. During an observation of the dining room lunch tray pass, it was noted that the resident was left unattended with her lunch tray for approximately 10 minutes while other residents received feeding assistance. The Assistant Director of Nursing (ADON) only began assisting the resident after all other residents had been served. This delay in providing feeding assistance could potentially place residents at risk for not receiving adequate care and services.
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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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Nursing homes near Midlothian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Midtowne Meadows Health & Rehab | 0.4 mi | ★★★★★ | 1 | 0 |
| Mansfield Medical Lodge | 7.5 mi | ★★★★★ | 17 | 0 |
| Cedar Hill Healthcare Center | 8.2 mi | ★★★★★ | 1 | 1 |
| Focused Care Of Waxahachie | 9.1 mi | ★★★★★ | 11 | 1 |
| Legend Oaks Healthcare And Rehabilitation - Waxaha | 9.2 mi | ★★★★★ | 9 | 0 |
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