Mid-Town Oaks Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of four sampled residents (Resident 1, Resident 3, and Resident 4) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's orders when Resident 1, Resident 3, and Resident 4's pain medication orders were not consistently followed. This failure had the potential for Resident 1, Resident 3, and Resident 4 to experience unrelieved pain and/or over-medication and not attain their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to protect the privacy of one of six sampled residents (Resident 1) when Resident 1's private health information was entered into Resident 2's chart. This failure gave Resident 2 access to Resident 1's personal health history.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the Department for one of six sampled residents (Resident 3) when Resident 3 told staff that Resident 4 threw a comb at him, striking him in the head. This failure had the potential for an allegation of abuse not being investigated.

Inspectors wroteBased on interview and record review, the facility failed to ensure the order for Restorative Program (designed to help residents maintain their highest level of physical function and prevent decline after rehabilitation) was followed for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience further decline in mobility and function. A review of the admission Record indicated Resident 1 was admitted early January 2026 with diagnoses including bilateral primary osteoarthritis (progressive condition causing pain, stiffness, swelling and reduced mobility) of knee and difficulty in walking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention practices when staff provided care to residents under contact isolation without the use of appropriate personal protective equipment (PPE) for two out of five sampled residents (Resident 1 and Resident 2). This failure increased the potential for the spread of infections among residents for a census of 97.

Inspectors wroteBased on the interview and record review, the facility failed to provide the requested medical records within two working days following a written request for one of four sampled residents (Resident 1), when electronic copies of medical records were requested on 1/22/26, and the request was fulfilled on 1/27/26, and a second request was made on 2/5/26 and fulfilled on 2/10/26. This failure resulted in the delayed provision of medical records to Resident 1, which decreased the likelihood of Resident 1 making informed medical decisions regarding her care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan to monitor and timely address clinical symptoms and complications for one of four sampled residents (Resident 1), when Resident 1 reported decreased left-hand strength, and when Resident 1 had a broken tooth and developed a tongue ulcer. These failures had the potential for Resident 1 to receive delayed and inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety for two of six sampled residents (Resident 1 and Resident 2), when: 1. Resident 1 eloped twice to a nearby hospital without facility's knowledge; and 2. Resident 2 eloped from facility and was found outside the front door on the ground near her wheelchair. These failures decreased the facility's potential to maintain residents' safety and prevent injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a current copy of advance directive (a legal document indicating resident preference on end-of-life treatment decisions) was available in the medical records for three out of 31 sampled residents (Resident 47, Resident 10 and Resident 85). This failure decreased the facility's potential to provide health care to residents when incapacitated (a state where you don't have the capacity or ability to accomplish something).

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 31 sampled residents (Resident 18 and Resident 86) were free from unnecessary psychotropic medications (drugs that alter brain chemistry to affect mood, thinking, and behavior), when:A Gradual Dose Reduction (GDR - tapering of dose to determine if symptoms can be managed at a lower dose or if a medication can be discontinued) was not attempted for Resident 18's olanzapine (an antipsychotic medication used to treat symptoms of psychosis). Resident 86's lorazepam (an antianxiety medication) as needed (PRN; pro re nata) order was beyond 14 days from 9/25/25; andResident 86's sertraline (an anti-depression medication) was administered without a manifestation. These failures increased the residents' potential to receive unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to follow the monthly pharmacist medication regimen reviews (MRR) for two of 31 sampled residents (Resident 18 and Resident 86), when:A Gradual Dose Reduction (GDR - tapering of dose to determine if symptoms can be managed at a lower dose or if a medication can be discontinued) was not attempted for Resident 18's olanzapine (an antipsychotic medication used to treat symptoms of psychosis); Resident 86's lorazepam (an antianxiety medication) as needed (PRN; pro re nata) order was beyond 14 days from 9/25/25; andResident 86's sertraline (an anti-depression medication) was administered without a manifestation. These failures decreased the facility's potential to follow the pharmacist recommendations and prevent residents from receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were safely stored and secured for a census of 96 residents, when:A medication refrigerator temperature log for December 2025 was found incomplete in the medication room at station-3;An expired and discontinued medication was found inside a medication refrigerator in the medication room at station-3;Eight loose tablets and three loose bubble packs were found in and behind medication cart 2's drawers at station-2; andFour over the counter (OTC) medications were stored insecurely inside Resident 89's room. These failures decreased the facility's potential to safely store and secure medications for its residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean environment for a census of 96 residents, when one out of four garbage dumpsters located outside the facility was not closed securely due to a gap between the lids. This failure decreased the facility's potential to maintain a safe environment and prevent pest infestation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a medication according to professional standards of quality for one of 31 sampled residents (Resident 86), when Resident 86's metoprolol succinate (a medication used to treat high blood pressure and heart failure) was not administered as ordered by the physician. This failure decreased the facility's potential to follow physician's orders and safely administer medications to residents as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 31 sampled residents (Resident 9 and Resident 61's) environment was safe and free of accident hazards, when: 1. Licensed Nurse (LN) 5 did not check Resident 61's wanderguard (a device that activates sensors on doors to alarm, alerting staff to intervene when wandering residents attempt to elope) functionality; and2. Resident 9 was smoking without supervision. These failures decreased the facility's potential to maintain residents' safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was consistent with professional standards of practice for one of 31 sampled residents (Resident 42), when Resident 42's nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not changed weekly. This failure decreased the facility's potential to prevent the risk of lung infection for Resident 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store food for a census of 96 residents, when an expired food item was available for use in the facility's kitchen. This failure decreased the facility's potential to prevent foodborne illness among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 87's) call light was within reach, when Resident 87 was in bed and could not reach the call light. This failure decreased the facility's potential to provide Resident 87 with assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was posted daily for a census of 96 residents, when staffing information was not updated for two days during the weekend. This failure decreased the facility's potential to have staffing information available for residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document and replace emergency medication kits (E-Kit: a kit/box containing medications and supplies for immediate use during a medical emergency) for a census of 95. This failure decreased the facility's potential for having accurate accountability of emergency medications, availability of emergency medications when needed, and meeting the residents' therapeutic needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications and medical supplies were labeled, stored, and disposed of consistently according to the facility's policies and procedures for a census of 95, when: 1. A medication refrigerator was not properly locked in the medication room, 2. Expired pharmaceutical products were found in a medication refrigerator, medication carts, and treatment carts, 3. Prescription pharmaceutical products did not have resident specific labels, and 4. Open date labels were not used to determine expiration dates. These failures had the potential for residents' medication misuse, drug diversion and medication errors and ineffectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed during lunch for a therapeutic diet (a modification of a regular diet to fit a person's particular nutritional needs, which could be related to a medical condition - usually prescribed by a physician), when 10 residents on a pureed diet for a census of 95 were served food that was not consistent with the recipe. This failure had the potential to compromise the residents' nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve pureed food (cooked food that has been processed in a blender) that was suitable to consume, when the kitchen prepared food items with inadequate textures for 10 residents on a pureed diet for a census of 95. This failure had the potential to compromise the residents' medical and nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food and maintain proper sanitizing procedures in accordance with professional standards for food service safety for a total of 95 residents, when: 1. Expired food was found in dry storage, 2. Metal serving containers were stacked wet in storage, 3. [NAME] sticky residue was found on the bottom surface of a metal serving container, and 4. Two of three sanitizer buckets contained sanitizers not within required disinfecting ranges. These failures had the potential to lead to contamination and food borne illness among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control for a census of 95 residents, when: 1. Staff members did not use gowns in rooms with enhanced barrier precautions (EBP, an infection control method that involves wearing gowns and gloves during high-contact interactions); 2. Certified Nursing Assistant 5 (CNA 5) did not use personal protective equipment (PPE) while providing care to Resident 21 in an EBP room; and 3. A clean-linen cart was stored uncovered in the basement. These failures had the potential for the spread and transmission of a communicable disease among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of 26 sampled residents (Resident 141), when the care plan did not address Resident 141's catheter (permanent catheter, a flexible tube inserted into a blood vessel) treatment services and interventions. This failure decreased the facility's potential to address the residents' individualized and specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards for one of 26 sampled residents (Resident 2), when an anticoagulant (medication that prevent or reduce blood clotting) monitoring was not in place for Resident 2. This failure had the potential to put Resident 2 at risk for having complications due to excessive bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was functioning for one of 26 sampled residents (Resident 37), when Resident 37 pushed the button for assistance and the call light did not turn on. This failure decreased the facility's potential to assist Resident 37 when needed.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) right to self-determination was maintained, when the facility canceled Resident 1's medical appointment without confirming with the resident or their family. The failure had potential to result in resident not receiving medical treatment and negatively impacting the resident's psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of four sampled residents (Resident 1), received treatment and care in accordance with professional standards of practice, when Resident 1's episode of low blood sugar was not addressed as directed by the management of hypoglycemia (low blood sugar) policy and procedure. The failure had the potential to result in Resident 1's hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for one of four sampled residents (Resident 2) when facility staff witnessed Resident 1's hand underneath Resident 2's shirt. This failure resulted in Resident 2 not being free from abuse and had the potential for Resident 2 to feel afraid and scared.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an incident of an injury of unknown origin for one of three sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the residents' shower room on the second-floor was sanitary. This failure decreased the facility's potential to provide residents with a sanitary bathroom and a homelike environment for a census of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1's), dignity and safety was protected when Certified Nurse Assistant (CNA) 1 threw a juice carton that hit the resident's water bottle, knocking it onto Resident 1. This failure resulted in Resident 1 to feel disrespected when the juice carton hit the resident's water bottle on the bedside table and fell onto Resident 1 in bed.

Inspectors wroteBased on observation and interview, the facility failed to follow infection control guidelines for 14 residents for a census of 96 when infection control precautions signs were not posted for five out of nine COVID positive rooms, doors were left open, garbage containers were outside of the rooms for nine out of nine COVID positive rooms,and two out of the nine rooms had broken garbage cans, causing staff to touch the lid with gloved contaminated hands to throw away contaminated PPE. These failures had the potential to spread infection and disease among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment for one of 27 sampled residents (Resident 15) when Resident 15 did not receive preventative treatment (low air loss mattress- a mattress designed to distribute body weight over a large surface, used to help prevent skin breakdown) to prevent pressure ulcer (PU-injury to the skin and underlying tissue from prolonged pressure on the skin). This failure resulted in Resident 15 developing a Stage 4 (full thickness skin loss, wound can extend to muscle and bone) pressure ulcer to her sacrococcyx area (tailbone area).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for 95 residents when: 1. Loose pills and pharmaceutical products were found at the back of bottom drawers of two medication carts, which could result in diversion of the loose medications; 2. An expired medication was available for Resident use in the medication cart, which put Residents at risk of receiving expired or outdated medications; 3. The facility failed to properly label and store all drugs and biological as per manufactures instructions, including expiration dates which put Residents at risk of receiving expired or outdated medication; and, 4. The facility failed to properly storage medications and left medications at the resident's bedside. These failures had the potential to contribute to medication error, unsafe medication use and storage, and diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement measures to provide a homelike environment for a census of 95 when: 1. The shower room for Nursing Station 1 had discolored grout along several tiles, had broken and missing tiles and was dirty; and, 2. Resident 10's clothing was lost and staff did not follow up in a timely manner to replace them. These failures had the potential to result in residents experiencing an environment that was not homelike.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident safety for a census of 95 when: 1. Electrical equipment was in use near water; and 2. Residents were smoking unsupervised and smoking materials were not stored properly. These failures had the potential to jeopardize the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for a census of 95 when an expired E-Kit (Emergency-Kit, storage box containing emergency supplies of medication) was not removed and replaced according to facility policy. This failure had the potential to allow administration of expired and ineffective emergency medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 4 sampled residents (Resident 9, and 148). 1. For Resident 148, Licensed Nurse (LN) 1 administered Resident's losartan potassium, a medication to treat high blood pressure, not in accordance with the Physicians Order. 2. For Resident 9, LN 2 administered Resident's fluticasone furoate 100 mcg (microgram, unit of measure), umeclinium 62.5 mcg, and vilanterol-25 mcg, a combination of three medications used to treat breathing issues, not in accordance with the Physicians Order. As a result, 2 errors were identified out of 31 opportunities for error during observation of medication administration; the facility medication error was 6.45%.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store, prepare, and serve food and maintain kitchen equipment and sanitary conditions in accordance with professional standards for food safety for a census of 95, when: 1. The Certified Nursing Assistant 3 (CNA 3) used a non-microwaveable base and dome to reheat Resident 21's food plate; 2. Undated food products were stored in the freezer and dry storage area; and, 3. Kitchen equipment and floor were not clean and in disrepair. These failures increased the potential for food-borne illnesses among the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control measures were followed for two of 27 sampled resident (Resident 65 and Resident 5) when: 1. Resident 65's privacy bag was placed on his indwelling catheter (a flexible plastic tube inserted in the bladder to constantly drain urine) after being on the floor; and, 2. No hand hygiene was completely during wound care for Resident 5. These failures had the potential to increase the chance of an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident call light system was properly functioning for seven residents (Resident 19, Resident 24, Resident 33, Resident 35, Resident 44, Resident 70 and Resident 75) of a census of 95 when their call lights were malfunctioning. This failure had the potential to unneccesarily extend the time residents waited to have their call lights answered.

Inspectors wrote2. A review of an admission record indicated Resident 300 was admitted to the facility on [DATE]. A review of Resident 300's MDS, dated [DATE], indicated Brief Interview of Mental Status (BIMS) score was 13 with good memory. A review of an admission record indicated Resident 297 was admitted to the facility in August 2023 with diagnoses including metabolic encephalopathy (problem in the brain), cognitive communication deficit (difficulty with thinking and using language), and bipolar disorder (mental illness). A review of Resident 297's MDS, dated [DATE], indicated BIMS score was 5 with memory problems. During a concurrent observation and interview on 9/11/23 at 9:55 a.m. with Resident 300, Resident 300 stated Resident 297 went into her room five times using the shared restroom, kept the restroom's door open while using it, and came naked to her room one time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively implement its grievance policy and procedure for a census of 95 when: 1. The grievance policy was not prominently posted in the facility; 2. The Resident Council President was not aware of how to file a grievance; and, 3. The grievance process was not thoroughly explained to newly admitted residents. These failures had the potential to result in residents not having a process to report concerns related to their care and treatment without fear of threat or reprisal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, an assessment that indicates a major decline or improvement in the resident's status) for one of 27 sampled residents (Resident 15) when Resident 15 developed a stage 4 (deep wound reaching the muscles, ligaments, and bones) pressure ulcer (PU) to her sacrococcyx (tailbone). This failure decreased the facility's potential to develop a personalized plan of care to prevent a further decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans were developed timely for two of 27 sampled residents (Resident 15 and Resident 148) when: 1. Resident 15 developed a stage 4 Pressure Ulcer (PU-full thickness skin loss, wound can extend to muscle and bone) was identified; and, 2. Resident 148 did not have a PU care plan. These failures had the potential to result in inadequate care being provided to residents.

Inspectors wrote1. A review of an admission record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD; chronic lung condition) and asthma (chronic lung disease). A review of Resident 25's Minimum Data Set (MDS; an assessment tool), dated 7/24/23, indicated Brief Interview of Mental Status (BIMS) score was 14 with good memory. During an interview on 9/11/23 at 10:58 a.m. with Resident 25, Resident 25 stated she received her inhaler late and if she did not receive it by 8 a.m., then she will start having chest tightness and wheezing. Resident 25 further stated she had a tight chest this morning because she received her inhaler at 10 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide bath/shower as scheduled for one out of 27 sampled residents (Resident 57) when Resident 57 did not get shower as scheduled. This failure had the potential to decrease cleanliness and comfort for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide resident centered care and services for two of 27 sampled residents (Resident 5 and Resident 71) when: 1. The facility did not follow the wound care order for Resident 5; and, 2. The facility did not have the call light within reach for Resident 71. These failures decreased the potential for the residents to receive effective treatment and necessary personal care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 27 sampled residents (Resident 63) receive trauma-informed care when his Post-Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) care plan did not include identified triggers and had not been revised at least quarterly. These failures had the potential to result in the re-traumatization of the resident and lead to unmet nursing needs.

Inspectors wroteBased on interview and record review, the facility failed to perform an annual evaluation for two employees out of six sampled personnel files. These failures reduced the potential for the facility to evaluate staff performance effectively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 21) of 27 sampled residents was free from an unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behaviors), when Resident 21's: 1. Indication/rationale for psychotropic medication was not documented and clinically justified; and 2. Behavioral symptoms were not monitored while receiving the psychotropic medication. This failure increased the facility's potential to administer unnecessary psychotropic medications to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage was properly contained for a census of 95 when one out of five dumpsters was not closed and the surrounding area was littered with trash. This failure had the potential to expose the facility environment to odors, pests and diseases.

Inspectors wroteBased on interview and record review the facility failed to provide adequate education for the arbitration agreement (a facility document that designates a third party to resolve a dispute between others) for three out of 27 sampled residents (Resident 49,65 and 92) when the arbitration agreement they signed was not explained so they could understand. This failure had the potential for residents to not fully understand the agreement.