Midlothian Healthcare Center

Penalties

• Sep 11, 2023 — Fine ($2,447)
• Sep 5, 2023 — Fine ($2,098)
• Aug 28, 2023 — Fine ($42,091)

Inspection findings

1. Feb 6, 2026 Health · 2 findings
   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 11, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 18, 2026 · CMS fire safety

2. Jan 31, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 1, 2026 · CMS health inspection

3. Dec 2, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 3, 2025 · CMS health inspection

4. Dec 18, 2024 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 22, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jan 22, 2025 · CMS health inspection

5. Dec 4, 2024 Fire Safety · 8 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Apr 14, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Dec 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     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.

     Corrected Dec 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Dec 23, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 23, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Mar 26, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Mar 27, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 26, 2025 · CMS fire safety

6. Oct 26, 2023 Fire Safety · 15 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Feb 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected Feb 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0030 Emergency Preparedness Deficiencies

     List the names and contact information of those in the facility.

     Corrected Feb 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0031 Emergency Preparedness Deficiencies

     Provide emergency officials' contact information.

     Corrected Feb 26, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Nov 17, 2023 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Nov 14, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Nov 14, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Nov 10, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 14, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0200 Egress Deficiencies

     Meet other general requirements.

     Corrected Feb 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Feb 26, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Mar 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Mar 7, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0915 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper power supply for life support equipment.

     Corrected Mar 5, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected Mar 6, 2024 · CMS fire safety

7. Aug 28, 2023 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Aug 29, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Aug 29, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Aug 29, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 05/01/2024
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• PATEL, DEEPAK — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• PATEL, DEEPAK — operational/managerial control, NOT APPLICABLE, since 05/01/2024
• PATEL, DEEPAK — adp of the snf, NOT APPLICABLE, since 05/01/2024
• STARK, KATHERINE — adp of the snf, NOT APPLICABLE, since 05/01/2024
• STARK, KATHERINE — operational/managerial control, NOT APPLICABLE, since 05/01/2024
• STARK, KATHERINE — managing control - governing body, NOT APPLICABLE, since 05/01/2024
• THOMPSON, JOHNNY — corporate officer, NOT APPLICABLE, since 05/16/2024
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 02/21/2024
• HAWKINS SPRING HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2024
• HAWKINS SPRING HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 10/16/2025
• SOUTHERN STAR NH, LLC — adp of the snf, NOT APPLICABLE, since 05/01/2024