Middleton Oaks Health and Rehabilitation

Inspectors wroteBased on record review, interview, observation and facility policy review the facility failed to implement the comprehensive person-centered care plan related to contracture management and splinting to prevent decline in Range of Motion (ROM) for one (1) of three (3) resident reviewed. Resident #1. Findings Included:Record review of the facility policy titled Prevention of Decline in Range of Motion revealed .3. Appropriate Care Planning, a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion .Record review of the Care Plan Report for Resident #1 revealed Focus: I have an ADL (activity of daily living) self-care performance deficit related to Stroke, Hemiplegia, and immobility putting me at risk for functional decline. Interventions: Apply splint to right ankle after breakfast. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide services to maintain or improve Range of Motion (ROM) and prevent further decline for one (1) of three (3) resident reviewed for ROM limitations Resident #1. Findings Included:Record review of the facility policy Prevention of Decline in Range of Motion, date reviewed/revised 11/10/2025 revealed Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .Observation on 3/31/26 at 10:15 AM, revealed a foot splint lying in the chair in Resident #1's room. Resident #1's right hand was contracted into a fist with no hand roll in place. [...]

Inspectors wroteBased on staff interview, record review, facility investigation review and facility policy review the facility failed to ensure residents were free from misappropriation of property when narcotics belonging to two residents were unaccounted for two (2) of three (3) residents reviewed for misappropriation. Resident #1 and Resident #2. Findings Include Findings Include Findings Include Review of the facility policy titled “Abuse, Neglect, Exploitation and Misappropriation” revised 11/16/22 revealed, “Policy: [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to maintain complete and accurate medical records for one (1) of three (3) residents reviewed for post-operative care. This deficient practice resulted in the omission of a physician-ordered post-operative appointment from the resident's medical record and contributed to the resident missing the appointment. (Resident #3). Findings Include Review of the facility policy titled Physician's Orders revealed Policy The center will ensure that all physician orders are accurately documented, promptly implemented, and authenticated in the resident's medical record in accordance with Center for Medicare and Medicaid (CMS) regulations and state requirements . [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene (Resident #5, #12, #51), wound treatment (Resident #11), staff assistance with meals (Resident #42) and treatment for nausea and vomiting (Resident #75), for six (6) of 22 resident care plans reviewed.

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to ensure necessary care and services were provided for one (1) of 38 residents (Resident #75) reviewed for PEG (percutaneous endoscopic gastrostomy) tube management and PRN (as needed) medication administration. Specifically, nursing staff failed to administer Zofran 4 mg (milligrams) PRN for vomiting/gagging on multiple documented occasions, despite physician orders and clinical indications. This failure resulted in Resident #75 experiencing vomiting and feeding intolerance, requiring cessation of tube feeding, and caused unnecessary discomfort.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure that staff received adequate education and training regarding the use and implementation of Enhanced Barrier Precautions (EBP). As a result, staff did not utilize the required personal protective equipment (PPE) during four (4) high-contact resident care activities observed, potentially putting all residents residing in the facility at risk for the spread of multidrug-resistant organisms (MDROs).

Inspectors wroteBased on observations, staff interviews, record reviews, and policy review, the facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) for five (5) of thirty-eight (38) sampled residents (Residents #11, #25, #32, #65, and #75). Specifically, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) during high-contact resident care activities (wound care and percutaneous endoscopic gastrostomy (PEG) tube handling), failed to prevent the reuse of a single-use medical device (PEG tube declogger), and failed to store a biliary drainage collection bag in a sanitary manner. These failures created an increased risk for the transmission of infectious organisms among residents requiring complex care.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to honor a resident's right to be treated with dignity and respect as evidenced by improper feeding practices and failure to cover biliary and urinary catheter drainage devices with privacy covers for three (3) of 93 residents residing in the facility. Resident #57, #65, and #439 The scope and severity of this deficiency was increased to E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings Include: Record review of the facility policy titled, Policies and Procedure with a revision date of 9/19/2017 revealed Subject; Catheterization, Male and Female Urinary .Foley bag to be covered by a privacy bag to preserve dignity of resident . [...]

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to provide a safe homelike environment as evidenced by missing air conditioner unit cover, damaged furniture, no fitted sheets and a foul odor from a stopped-up toilet for four (4) of 93 residents residing in the facility. Residents #3, #22, #28 and #47 The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey. Findings Include: Review of the facility policy titled Policies and Procedures unrevised revealed under, Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for three (3) of 38 sampled residents. Resident #5, #12 and #51. The scope and severity of this deficiency was cited at E for a pattern of deficiency. This deficiency was also cited on the last annual recertification survey.

Inspectors wroteBased on observation, resident/staff interview and record review, the facility failed to ensure a resident's medications were not left unattended in the resident's room for one (1) of 38 sampled residents. Resident #28. The scope/severity for this deficiency was increased to E due to previous citation on the last annual recertification survey.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide a resident with adaptive equipment and staff assistance for three (3) of three (3) dining observations.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to provide accommodation of needs for a residents call light not being within reach for two (2) of three (3) survey days. Resident #71 Findings Include The facility provided a statement on letterhead signed by the Administrator and dated 3/27/25, (Proper name of the facility) does not have a specific policy for Call Lights. Resident #71 An observation of Resident # 71 on 3/25/25 at 11:25 AM revealed he was lying in bed. Further observation revealed his call light was hanging over a small picture on the wall, and the end of the call button was on the floor behind a bedside dresser. The resident did not have access to his call light. An observation on 3/26/25 at 10:43 AM of Resident #71 revealed he was sitting in a chair in his room. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure there was a physician's order and provide catheter care to a resident with an indwelling catheter for one (1) of eight (8) residents with an indwelling catheter reviewed. Resident #439 Findings Include: Review of the facility provided statement on letterhead dated 3/27/25 and signed by the Administrator revealed, (Proper name of the facility) does not have a specific policy for obtaining physician orders. An observation of Resident #439 on 3/25/25 at 11:27 AM revealed he was lying in bed. His catheter drainage bag was hanging on the lower bed rail, with yellow urine visible from the hallway. Record review of Resident #439's Order Summary Report with active orders as of 3/26/25 revealed the resident did not have an order for the urinary catheter or catheter care orders. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to document if wound treatments had been completed for a resident with a Stage 4 pressure ulcer for one (1) of three (3) residents with wounds reviewed.

Inspectors wroteBased on record review, staff interviews, resident interview and facility policy review, the facility failed to complete timely reporting of a resident involved accident in the facility's wheelchair lift van to the State Agency, for one (1) of four (4) residents reviewed for wheelchair transportation safety. Resident #1 Findings Include: Review of the facility policy titled, Policies and Procedures, with a revision date of 11/16/2022, revealed . Employee Obligation . to report such information immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . to other officials in accordance with State law. Report the result of all investigations . [...]

Inspectors wroteBased on observation, and staff and resident interview the facility failed to provide a safe clean environment as evidenced by a dirty wheelchair with a torn arm rest for Resident #249 and dirty floors throughout the facility, scuffed painted areas, gouged sheetrock, broken drawers, broken window and sharp areas on resident doors for four (4) of 4 survey days.

Inspectors wroteBased on observations, staff interviews, record review and facility policy review the facility failed to honor a resident's dignity as evidence by posting a sign on a resident's door concerning care for one (1) of 96 residents residing in the facility.

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to follow up on a grievance from Resident Council meetings related to answering call lights in a timely manner for two (2) of 10 residents in the Resident Council Meeting.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to complete a level one (1) Preadmission Screen (PAS) for a resident admitted to the facility for 1 of three (3) residents reviewed for Preadmission Screening and Resident Review (PASARR). Resident #81.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plans for four (4) of the twenty-eight resident care plans reviewed. Resident #32, Resident #33, Resident #57 and Resident #248.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) care for four (4) of 97 residents observed during the initial tour related to nail care for Resident #32, and failure to shave Residents #33, #57 and #248 and provide a shower for Resident #248.

Inspectors wroteBased on observation, resident/staff interview, record review, and facility policy review the facility failed to ensure medications were not left in the resident's room for one (1) of 28 sampled residents. Resident #4.

Inspectors wroteBased on observation, staff interviews and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by, missing biohazard containers in one (1) of nine (9) transmission based precaution rooms, failure to disinfect rooms that required specialized cleaning and appropriate chemicals related to a specific organism for three (3) of nine (9) resident rooms, allowing a urinary catheter bag to lie on the floor, attempting to use contaminated oxygen tubing from the floor on a tracheostomy humidifier and attempting to use a soiled washcloth during catheter care for one (1) of six (6) care observations. Resident #8, #54, #75 and #81.

Inspectors wroteBased on resident and staff interviews and facility policy review, the facility failed to deliver mail to the residents on Saturday for 10 of 10 residents in Resident Council, with the potential to affect all residents.

Inspectors wroteBased on observation, staff interview, facility policy review, and record review, the facility failed to prevent the likelihood of foodborne illness as evidence by out of date and unlabeled food items in the refrigerator and failed to clean the ice machine as evidence by black substance on the ice and the interior walls of the kitchen ice machine for two (2) of two (2) kitchen tours.