Middleton Oaks Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Winona, Mississippi.
- Location
- 627 Middleton Road, Winona, Mississippi 38967
- CMS Provider Number
- 255171
- Inspections on file
- 23
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Middleton Oaks Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
Narcotics belonging to two residents were unaccounted for after discrepancies were found in the controlled drug count sheets, with counts altered and documentation missing. An LPN failed to properly reconcile and document narcotic counts, and a discontinued medication was left on the cart. The DON confirmed the missing medications and incomplete records, and the nurse on duty did not cooperate with the investigation.
A resident admitted with a below-the-knee amputation did not attend a required post-operative orthopedic appointment because the physician's order for the appointment was not entered into the medical record. The admitting nurse failed to document the order, and the DON and ADON did not identify the omission during their review, resulting in the missed appointment.
Multiple residents did not receive care as outlined in their care plans, including personal hygiene (such as nail and facial hair care), wound treatment documentation, staff assistance with meals, and administration of PRN medication for nausea and vomiting. Observations and interviews confirmed that residents' needs were unmet despite clear care plan interventions, and staff acknowledged that required care and documentation were not consistently provided.
Nursing staff did not administer a prescribed PRN antiemetic (Zofran) to a resident with a PEG tube who experienced multiple episodes of vomiting and feeding intolerance, despite physician orders and clear clinical indications. The omission was confirmed by documentation and interviews, and resulted in unnecessary discomfort and interruption of enteral feeding.
Staff did not receive education or training on Enhanced Barrier Precautions (EBP), resulting in multiple instances where required PPE was not used during high-contact care activities such as wound care and medication administration via PEG tube. Interviews with nurses, CNAs, and facility leadership confirmed the absence of EBP training and documentation, with the staff educator and administrator acknowledging the deficiency.
Staff failed to use Enhanced Barrier Precautions during high-contact care activities such as wound care and PEG tube handling, did not follow single-use device protocols for a PEG tube declogger, and improperly stored a biliary drainage collection bag on the floor. Multiple staff members and leadership confirmed a lack of training and policy implementation regarding infection control practices, resulting in increased risk for transmission of infectious organisms among residents requiring complex care.
Staff failed to maintain resident dignity by feeding a resident while standing over them in bed and by not covering urinary and biliary catheter drainage bags for three residents, making the contents visible to others. Staff and policy reviews confirmed these actions did not align with dignity standards, and the affected residents had significant medical conditions requiring such care.
Multiple residents experienced unsafe and unclean living conditions, including a missing air conditioner unit cover, damaged furniture with sharp edges, a dirty personal fan, and a persistent foul odor from a stopped-up toilet. Staff interviews revealed lack of communication and unclear responsibilities for maintenance and cleaning, resulting in unresolved hazards and discomfort for residents with varying cognitive abilities.
Surveyors identified a pattern of deficient ADL care, where three residents were observed with untrimmed, dirty nails and unshaven facial hair. Residents expressed a need for grooming, and staff interviews confirmed that nail and shaving care responsibilities were not consistently followed, especially for diabetic and dependent residents. Nursing and CNA staff acknowledged lapses in providing routine hygiene and grooming, resulting in residents not being maintained according to their needs and preferences.
A resident's IV antibiotic medication was left unattended on a bedside table, visible from the open doorway, while the nurse awaited restarting the resident's peripheral IV. Multiple staff confirmed the medication should not have been left unattended, and the facility lacked a specific policy addressing this issue. The resident was cognitively intact and had multiple chronic diagnoses.
A resident with a history of cerebral infarction and muscle weakness, requiring substantial assistance with eating, was observed during multiple meals without adaptive utensils or a divided plate, and without staff assistance, despite facility policy and care plan requirements. Staff interviews confirmed the resident's needs were known but not met, and there were no physician orders for the necessary adaptive equipment.
A resident with Parkinson's disease and dyskinesia was observed on multiple occasions without access to a call light, as it was found hanging over a wall picture and on the floor behind a dresser. Both an LPN and a CNA confirmed the call light was not within reach, and the facility lacked a specific policy regarding call light accessibility.
A resident returned from the hospital with an indwelling catheter, but staff did not obtain a physician's order for the catheter or catheter care. Observation and record review confirmed the absence of necessary orders, and staff interviews revealed that the admitting nurse did not complete the required assessment or ensure orders were entered. The facility also lacked a specific policy for obtaining physician orders, resulting in the resident not receiving proper catheter care or monitoring.
A resident with a Stage 4 pressure ulcer did not have wound care treatments properly documented on twelve occasions, despite facility policy requiring such documentation. The Wound Care RN admitted to missing documentation due to system entry issues, and the DON confirmed the lack of records for these treatments, which are essential for continuity of care.
Failure to Implement Care Plan for Ankle Splint and ROM Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for contracture management and splinting to prevent decline in range of motion for one resident. The facility’s policy on prevention of decline in range of motion required that, based on the comprehensive assessment, the facility provide interventions, exercises, and/or therapy to maintain or improve ROM. The resident’s care plan, initiated on 8/1/25, identified an ADL self-care performance deficit related to stroke, hemiplegia, and immobility, placing the resident at risk for functional decline. The care plan interventions directed staff to apply a splint to the right ankle after breakfast, provide passive stretch to the right ankle after applying the splint, remove the splint at lunchtime, reapply the splint after supper with passive stretch, and remove the splint at bedtime. On observation, the resident’s ankle splint was not in use and was found lying in a chair in the resident’s room, and the resident was unsure when the splint was last applied. The PTA reported that the resident had developed foot drop and that the ankle splint could no longer be placed without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON stated that the care plan was used to inform staff how to care for the resident and verified that staff failed to follow the care plan when they did not apply the ankle splint. Record review showed the resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an MDS assessment indicated a BIMS score of 5, reflecting cognitive impairment at the time of the deficiency.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Narcotics Misappropriation Due to Inadequate Documentation and Security
Penalty
Summary
The facility failed to protect residents from misappropriation of property when narcotics belonging to two residents were unaccounted for. A discrepancy was identified on the Controlled Drug Count Sheet, with numbers scratched out and rewritten, resulting in a two-card difference. The narcotic count dropped from 34 to 31 packages/sheets without documentation of removal, and the Master List Controlled Drug form for a specific period was missing. One resident's discontinued Norco medication remained on the cart, and another resident's active Norco was also unaccounted for. Staff interviews confirmed that narcotics are supposed to be reconciled each shift, but the process was not properly followed, and documentation was incomplete or altered. The Director of Nursing confirmed that the missing narcotics were not accounted for and that the Master List Controlled Drug form could not be located. The nurse on duty during the shift in question refused to assist with the investigation and was subsequently suspended and terminated. The facility's policy required residents to be free from misappropriation of property, but the failure to properly document, reconcile, and secure narcotics led to the loss of controlled substances belonging to two residents. The residents involved had diagnoses of hypertensive disease without heart failure and cerebral infarction, respectively.
Failure to Document Physician-Ordered Post-Operative Appointment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of three residents reviewed for post-operative care. Specifically, a physician-ordered post-operative appointment was omitted from the resident's medical record, resulting in the resident missing the scheduled appointment. The facility's policy requires that all physician orders be accurately documented and promptly implemented in accordance with CMS regulations and state requirements. However, review of the resident's "After Visit Summary" upon admission showed an order for a post-operative visit, but this order was not entered into the resident's order summary report, and only a later appointment was documented. Interviews with the Director of Nursing (DON) revealed that the admitting nurse, who was responsible for entering all admission orders, failed to document the post-operative appointment. The DON and Assistant Director of Nursing (ADON) also missed the omission during their review of admission orders in the clinical meeting the following day. As a result, the resident, who was admitted with a diagnosis of acquired absence of the left leg below the knee, did not attend the required post-operative orthopedic appointment due to the missed order entry.
Failure to Implement Comprehensive Care Plans for Hygiene, Wound Care, Meal Assistance, and Symptom Management
Penalty
Summary
The facility failed to implement comprehensive care plans for multiple residents, resulting in unmet needs in personal hygiene, wound care, meal assistance, and treatment for nausea and vomiting. Several residents were observed with untrimmed, dirty fingernails and facial hair, despite care plans specifying regular nail and grooming care. Interviews with residents and staff confirmed that these personal hygiene interventions were not carried out as documented in the care plans. For example, one resident with diabetes and impaired vision had long, jagged fingernails with a brown substance underneath and expressed a desire for a bath, shave, and nail trim. Another resident with hemiplegia had fingernails approximately one inch long, dirty, and unshaven, also expressing a wish for grooming, which staff confirmed had not been provided according to the care plan. In the area of wound care, a resident with a pressure ulcer had a care plan intervention for daily wound treatments and monitoring. However, documentation revealed that wound treatments were not recorded for 12 days in one month. The wound care RN stated she performed the treatments but failed to document them, and the DON confirmed that documentation is a required part of the care plan process. This lack of documentation meant there was no verification that the care plan was followed as required. For meal assistance and medication administration, the facility did not follow care plans for residents requiring staff support. One resident who required staff assistance with eating was repeatedly observed eating meals unassisted, contrary to the care plan and staff interviews. Another resident with a history of GERD and a physician's order for as-needed Zofran for nausea and vomiting experienced multiple episodes of vomiting and gagging, but the ordered medication was not administered on those occasions. The DON and MDS Coordinator confirmed that the care plans for meal assistance and medication administration were not followed, resulting in unmet resident needs.
Failure to Administer PRN Medication for Vomiting in PEG Tube Resident
Penalty
Summary
Nursing staff failed to administer Zofran 4 mg as needed for vomiting and gagging to a resident with a PEG tube, despite active physician orders and documented clinical indications. On multiple occasions, including when the resident experienced vomiting and feeding intolerance, the as-needed medication was not given, as confirmed by both the Electronic Medication Administration Record (EMAR) and progress notes. This resulted in the resident experiencing repeated episodes of vomiting and discomfort, and required cessation of tube feeding. The resident involved had a history of dysphagia following cerebral infarction, gastrostomy status, gastro-esophageal reflux disease, and acquired absence of other specified parts of the digestive tract. The resident was severely cognitively impaired and unable to communicate needs effectively. Facility policy required medications to be administered as prescribed and in a timely manner, but staff did not follow these protocols, as confirmed by interviews with the Regional Director of Clinical Services and the Director of Nursing.
Failure to Educate Staff on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that nurses and nurse aides received adequate education and training regarding Enhanced Barrier Precautions (EBP), as required by facility policy. Observations revealed that during four high-contact resident care activities, staff did not utilize the required personal protective equipment (PPE), specifically gowns and gloves, as outlined in the EBP policy. These activities included medication administration via PEG tube and wound care for multiple residents. Staff members involved in these activities, including LPNs, RNs, and CNAs, were observed not using EBP during care. Interviews with various staff members, including the wound care nurse, CNAs, the infection control nurse, the staff educator, and the administrator, confirmed that there had been no education or training on EBP provided to staff. The staff educator stated that EBP was not included in the competencies for staff or new hires, and there was no documentation of EBP education prior to her hire date. The administrator acknowledged that a breakdown in EBP practice occurred due to significant staff turnover and confirmed the lack of staff education and documentation regarding EBP.
Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) for several residents, as evidenced by staff not using Enhanced Barrier Precautions (EBP) during high-contact care activities such as wound care and percutaneous endoscopic gastrostomy (PEG) tube handling. Observations revealed that wound care nurses and certified nursing assistants did not don gowns or follow EBP protocols while providing wound care to multiple residents with pressure ulcers and diabetic wounds. Staff interviews confirmed a lack of knowledge and training regarding EBP, and the facility's leadership acknowledged that EBP had not been practiced or taught due to recent staff turnover. Additionally, improper handling of medical devices was observed. An LPN reused a single-use PEG tube declogger for a resident, contrary to manufacturer instructions, and stored the device in an undated, opened package. The same LPN also administered medications via PEG tube without using a gown as required by EBP. Staff interviews confirmed that they had not received training on EBP or the correct use of single-use devices, and facility leadership verified that alternative methods should have been used for tube declogging. Further, the facility failed to ensure sanitary storage of a biliary drainage collection bag for a resident with a biliary drain. The drainage bag was observed lying on the floor, and both nursing staff and leadership confirmed this was an infection control issue. Review of facility policies revealed no guidance on the storage of biliary tube bags, and staff acknowledged the risk of infection associated with improper storage. These deficiencies were identified through direct observation, staff interviews, and record reviews.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect, as evidenced by improper feeding practices and the lack of privacy covers for urinary and biliary catheter drainage devices for three residents. One resident was observed being fed by a CNA who stood over him while he was in bed, rather than sitting at bedside, which was confirmed by the CNA and the Nursing Educator as not being in line with maintaining resident dignity. The facility did not have a policy related to providing dignity during meal assistance. Two other residents were observed with urinary catheter and biliary drainage bags that were not covered with privacy covers, making the contents visible from the doorway or hallway. Staff interviews, including with an LPN and the ADON, confirmed that the absence of privacy covers was a dignity issue. Facility policy required urinary catheter bags to be covered, but there was no specific policy for biliary drainage tubes. The affected residents had medical conditions such as sequelae of cerebral infarction, malignant neoplasm of the pancreas, and hemiplegia following cerebral infarction.
Failure to Maintain Safe and Homelike Environment for Multiple Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as evidenced by multiple observations and interviews. In one instance, a resident's air conditioner/heating unit cover was found on the floor for at least two consecutive days, with the resident stating that staff were aware but had not resolved the issue. The maintenance supervisor was not informed of the problem, and there was no documentation in the maintenance log. Another resident's dresser had an 18-inch section of jagged, sharp trim protruding, which staff acknowledged could cause injury, but neither the maintenance supervisor nor the assistant director of nursing were aware of the hazard, and it was not documented for repair. Additionally, a resident's personal fan was observed to have a significant buildup of lint and dust, which the resident had previously requested to be cleaned. There was confusion among staff regarding responsibility for cleaning such items, with housekeeping, maintenance, and CNAs each providing different answers. The fan remained uncleaned, and the resident refrained from using it due to its condition. In another case, a resident's room had a persistent foul odor due to a toilet that had been stopped up for about a month. Staff and the maintenance supervisor confirmed the ongoing issue, with repeated but ineffective attempts to address it, and the problem was well known among staff but unresolved. The residents involved had varying degrees of cognitive function, with some being cognitively intact and others having severe impairment or dementia. The deficiencies were observed through direct inspection, staff and resident interviews, and review of facility records and policies. The issues identified were not isolated incidents, as similar deficiencies had been cited in the previous annual recertification survey, indicating a pattern of failure to maintain the physical environment according to facility policy and regulatory requirements.
Failure to Provide Adequate ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to maintain personal hygiene for three residents, as evidenced by observations, interviews, and record reviews. One resident, who was cognitively intact and diabetic, was observed on two occasions with long, uneven fingernails containing a brown substance underneath, visible facial hair, and reported needing a bath and grooming. The LPN confirmed that nail care for diabetic residents was a nursing responsibility and acknowledged the resident's unkempt condition and odor. Another resident, with moderate cognitive impairment and a history of hemiplegia, was observed with long fingernails containing a dark brown substance and significant facial hair growth. The resident expressed a desire for grooming, stating it had been too long since his last shave and nail trim. The CNA assigned to this resident admitted she did not ask about shaving or nail care and was unaware of the protocol for diabetic residents. The LPN and DON both confirmed the resident's nails were dirty and too long, and that grooming should have been provided during bath days without requiring the resident to request it. A third resident, who was cognitively intact and required assistance with personal care due to spinal cord injury and other diagnoses, was found with excessively long and jagged toenails. The CNA responsible for this resident acknowledged that toenail care was her responsibility for non-diabetic residents but had not performed it. Both the LPN and DON confirmed the resident's toenails were overdue for trimming and not maintained according to the resident's needs and preferences. These findings demonstrate a pattern of failure to provide necessary ADL care, specifically in grooming and nail hygiene, for multiple residents.
Unattended IV Medication Left in Resident Room
Penalty
Summary
A deficiency was identified when a bag of intravenous (IV) fluids with a vial of medication attached was observed lying unattended on a resident's bedside table. The medication was confirmed by the resident to be her antibiotic, which was awaiting administration after her peripheral IV was to be restarted. The medication was visible from the open doorway, and the resident's room door was open to the hallway, making the medication accessible to others. Multiple staff members, including a registered nurse, the RN supervisor, and the assistant director of nursing, confirmed that the medication should not have been left unattended and acknowledged that this was inappropriate. Record review indicated that the resident involved was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, and had diagnoses including polyneuropathy, COPD, and type 2 diabetes mellitus. The facility did not have a specific policy addressing unattended medication, as confirmed by a statement from the administrator. The scope and severity of the deficiency were increased due to a previous citation for a similar issue on the last annual recertification survey.
Failure to Provide Adaptive Eating Equipment and Assistance
Penalty
Summary
Staff failed to provide a resident with adaptive eating equipment and necessary assistance during three observed meals. The resident, who had a history of cerebral infarction, muscle weakness, and required substantial to maximal assistance with eating, was observed eating independently without adaptive utensils or a divided plate, despite struggling to hold her spoon. The facility's policy required assistive devices to be provided as identified in the individualized care plan, but these were not present during the observations. Interviews with staff confirmed that the resident was supposed to have a divided plate and assistance from a CNA during meals, as indicated on her meal ticket and recommended by the occupational therapist. However, the CNA assigned was unaware of the resident's needs, and there were no physician orders for the adaptive equipment. The resident's Minimum Data Set assessment also documented her need for substantial assistance with eating, but this support was not provided during the observed meals.
Failure to Ensure Call Light Accessibility for Resident with Parkinson's Disease
Penalty
Summary
Staff failed to ensure that a resident's call light was within reach on two of three survey days. Observations showed that the call light was hanging over a picture on the wall, with the end of the call button on the floor behind a bedside dresser, making it inaccessible to the resident. The resident was observed both lying in bed and sitting in a chair during these times, and in both instances, the call light was not accessible. Interviews with an LPN and a CNA confirmed that the call light should have been within the resident's reach and acknowledged that it was not. The LPN stated that she frequently found call lights out of reach and confirmed that the resident would not be able to call for help if needed. The resident's admission record indicated a diagnosis of Parkinson's disease with dyskinesia, which may impact mobility and the ability to access the call light. The facility did not have a specific policy for call lights.
Failure to Obtain Physician Orders and Provide Catheter Care
Penalty
Summary
A deficiency occurred when a resident returned from the hospital with an indwelling urinary catheter, but the facility failed to obtain a physician's order for the catheter or for catheter care. Observation revealed the resident in bed with a catheter drainage bag visible, and record review confirmed there were no active orders related to the catheter. Staff interviews indicated that the admitting nurse did not complete the necessary hospital return assessment or ensure that appropriate orders were entered into the system. The facility's daily stand-up meetings, intended to capture and correct new orders, did not identify or resolve the missing catheter orders for this resident. Further review of the resident's progress notes and admission record confirmed the presence of an indwelling catheter and relevant medical diagnoses, including hemiplegia and hemiparesis following a cerebral infarction. Staff interviews acknowledged that without physician orders, the resident would not receive proper catheter care or monitoring for complications. The facility also lacked a specific policy for obtaining physician orders, as confirmed by the administrator.
Failure to Document Wound Care for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to document the completion of wound treatments for a resident with a Stage 4 pressure ulcer. According to the facility's policy, nurses are required to apply a clean dressing to wounds as ordered and document the procedure in the medical record. A review of the resident's medical orders showed a daily wound care regimen for a sacral pressure ulcer, which was in place for over a month. However, the electronic treatment administration record (ETAR) for March showed that documentation was missing for twelve specific dates when the wound care should have been administered. Interviews with the Wound Care RN revealed that she performed the wound treatments on the days she worked but failed to document them in the ETAR, attributing the oversight to the way entries were displayed in the system. The Director of Nursing confirmed that documentation was not completed for twelve wound treatments and emphasized that accurate documentation is necessary for continuity of care. The resident involved had a history of a sacral pressure ulcer and Type 2 Diabetes Mellitus and was rarely or never understood, according to the most recent assessment.
Latest citations in Mississippi
A resident with hemiplegia, hemiparesis, and cognitive impairment had a care plan directing staff to apply and remove a right ankle splint at specific times each day and to provide passive stretching to prevent decline in ROM. Observation found the splint not in use and lying on a chair, and the resident was unsure when it was last applied. A PTA reported the resident had developed foot drop and that the splint could no longer be applied without additional therapy, attributing this to the splint not being used daily as ordered. The DON confirmed that staff failed to follow the established care plan for splint application and ROM management.
A resident with hemiplegia and hemiparesis after a cerebral infarction, and severe cognitive impairment (BIMS 5), had physician and therapy orders for right-hand and right-ankle splinting with passive ROM to manage contractures and maintain ROM. Surveyors observed a foot splint lying unused and the resident’s right hand contracted into a fist without a hand roll. The resident could not recall when the foot splint was last applied and reported never having a hand roll. An LPN was unaware of the need for the splint and confirmed no hand roll was in use. Records showed the hand splint order was discontinued at the responsible party’s request due to pain, but OT was not notified and no alternative such as a hand roll was initiated. PT had documented improved ankle ROM and recommended a PODUS boot, while a PTA later reported the resident had developed foot drop related to the ankle splint not being applied as ordered. The DON confirmed that daily ankle splint orders existed and that the hand splint was discontinued without alternative interventions to prevent contracture.
The facility failed to protect resident narcotic medications from misappropriation when an LPN handed over a medication cart’s narcotic keys to an RN without performing required narcotic counts before and after the transfer, and the cart was later found unlocked in the nurses’ station. During the subsequent shift change count, staff discovered multiple missing doses of oxycodone-acetaminophen and hydrocodone-acetaminophen prescribed PRN for pain to four residents with conditions including dementia, COPD, dysphagia, and diabetic neuropathy. Review of individual controlled drug logs showed corrected balances to account for the missing tablets, confirming that controlled substances were unaccounted for during the period of unsecured cart access and improper key control.
Two ambulatory residents with dementia, severe cognitive deficits, and known wandering behavior, each wearing a wander guard bracelet, were able to exit through a unit door when a visitor held it open, despite the door alarm sounding and prior observations that they frequently walked together and approached doors. An LPN responded to the alarm and, along with other staff, initiated a search when the residents could not be found on the unit; staff ultimately located the residents across a four-lane highway and returned them to the building without injury. The incident occurred despite facility policies requiring use of a security system for residents unable to protect themselves from harm by wandering, and staff and leadership acknowledged that the residents had a history of walking the halls together and going to doors, and that increased monitoring and restricting visitor access to door codes could have prevented the elopement.
A cognitively impaired resident with dementia, agitation, and a history of wandering was previously assessed by the IDT as not being at risk for elopement and did not have elopement precautions in place. On one occasion, a visitor exited through the front door without realizing the resident followed outside, and staff later discovered the resident alone on the front porch after being missing for several minutes. An LPN and CNA participated in locating and returning the resident, and the incident revealed that supervision and elopement risk assessment were insufficient for this resident.
A resident with Type 2 DM and moderately impaired cognition had two unstageable heel DTIs documented on the MDS and physician orders for treatment to both heels, but the comprehensive care plan did not include any problem, goals, or interventions related to these pressure injuries. LPNs responsible for MDS and care plan completion acknowledged the omission and stated that although they periodically audit by comparing orders to the care plan, this situation was missed. The DON reported she expected the wound care nurse to update the care plan with new wound treatment orders, while an RN stated she could update interventions but had not been trained to create a new focused care plan and was unaware it was her responsibility to add the DTI treatment orders to the care plan.
A controlled substance prescribed for a cognitively intact resident with a left femur fracture was delivered and signed for by an LPN but was not entered on the narcotic accountability record or narcotic box package count and was later found to be missing. One LPN reported receiving the blister pack of thirty Hydrocodone/Acetaminophen 10-325 mg tablets from another LPN, placing it on the nurses’ station, and leaving the area, while both LPNs stated they were in the medication room as the medication remained unattended. The DON and Administrator confirmed that staff failed to secure the controlled medication as required by facility policy and that the missing tablets could not be located.
Surveyors found that staff failed to properly secure and store medications for two residents. For one resident, an LPN received a delivery of Hydrocodone-Acetaminophen, passed it to another LPN, and the controlled medication was left unattended at the nurses’ station instead of being immediately locked and entered into the narcotic count, after which it could not be located. For another resident, two bottles of Lorazepam oral concentrate, documented on the narcotic record and labeled to be protected from light and refrigerated, were observed stored in a locked medication cart rather than in the designated medication refrigerator, even though staff acknowledged knowing the manufacturer’s refrigeration requirement.
A resident with hemiplegia and hemiparesis following cerebral infarction was transferred by facility van to a psychiatric hospital for evaluation and was later determined by the facility to be discharged due to aggressive behavior and threats, with staff stating they could not meet the resident’s needs. The Administrator and Social Services Director communicated with the psychiatric facility and the resident’s family about finding alternative placement and informed the family the resident would not be allowed to return, but no formal involuntary discharge notice or written appeal rights were provided, and no physician discharge order was documented, contrary to facility policies requiring a completed transfer form and written notice of transfer/discharge with appeal information.
The facility did not adequately investigate, address, or resolve repeated grievances about food quality and temperature raised through Resident Council meetings. Over several months, residents reported that weekend meals were bad, food was consistently cold, beverages lacked sufficient ice, and breakfast items were hard or unpalatable. While limited steps such as using temperature-holding containers, sending trays out faster, and in-servicing dietary staff were noted, there was no documented monitoring, follow-up, or evaluation of effectiveness. Cognitively intact residents continued to report cold, poor-tasting food, and staff, including the Dietary Manager and Social Services, acknowledged awareness of the complaints without evidence of thorough follow-up or resolution.
Failure to Implement Care Plan for Ankle Splint and ROM Management
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for contracture management and splinting to prevent decline in range of motion for one resident. The facility’s policy on prevention of decline in range of motion required that, based on the comprehensive assessment, the facility provide interventions, exercises, and/or therapy to maintain or improve ROM. The resident’s care plan, initiated on 8/1/25, identified an ADL self-care performance deficit related to stroke, hemiplegia, and immobility, placing the resident at risk for functional decline. The care plan interventions directed staff to apply a splint to the right ankle after breakfast, provide passive stretch to the right ankle after applying the splint, remove the splint at lunchtime, reapply the splint after supper with passive stretch, and remove the splint at bedtime. On observation, the resident’s ankle splint was not in use and was found lying in a chair in the resident’s room, and the resident was unsure when the splint was last applied. The PTA reported that the resident had developed foot drop and that the ankle splint could no longer be placed without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON stated that the care plan was used to inform staff how to care for the resident and verified that staff failed to follow the care plan when they did not apply the ankle splint. Record review showed the resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and an MDS assessment indicated a BIMS score of 5, reflecting cognitive impairment at the time of the deficiency.
Failure to Implement ROM and Splinting Orders Resulting in Contractures and Foot Drop
Penalty
Summary
The facility failed to provide ordered range of motion (ROM) and splinting interventions to prevent decline in ROM for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident was admitted with these diagnoses and had physician orders and therapy recommendations for contracture management and splinting. An OT evaluation documented decreased ROM in the right upper extremity and recommended a resting hand splint and a restorative splint and brace program, with a subsequent OT evaluation recommending continuation of the contracture management and splinting program. A physician order directed staff to apply a right-hand splint after breakfast, provide passive stretch to the right elbow, wrist, and hand once daily, and remove the splint before dinner. Another physician order required application of a right ankle splint after breakfast and after supper with passive stretching following application. The facility’s own policy stated that residents without limited ROM should not experience a reduction in ROM unless clinically unavoidable. During observation, surveyors noted a foot splint lying unused in the resident’s chair and the resident’s right hand contracted into a fist without a hand roll in place. The resident reported not knowing when the foot splint was last applied and stated she had never had a hand roll. An LPN stated she did not know why the splint was in the room, believed the resident was not required to wear it, and confirmed the resident did not have a hand roll. Record review showed the right-hand splint order was discontinued at the responsible party’s request due to pain, but the OT reported she had not been notified of this discontinuation and stated a hand roll should have been initiated when the splint was stopped; she further stated the resident’s hand was now contracted into a fist. A PT discharge summary documented improved right ankle ROM with therapy and recommended a PODUS boot daily for up to five hours, while a PTA later reported the resident had developed foot drop and that the ankle splint could no longer be applied without additional therapy, confirming this was related to the splint not being applied daily as ordered. The DON verified that there were physician orders for daily ankle splinting and acknowledged that the right-hand splint was discontinued without alternative interventions to prevent contracture. The resident’s MDS showed a BIMS score of 5, indicating severe cognitive impairment.
Failure to Secure Narcotic Medications and Maintain Key Control
Penalty
Summary
The deficiency involves the facility’s failure to protect resident medications from misappropriation on one of four medication carts, resulting in missing controlled substances for four residents. The facility’s abuse, neglect, and exploitation policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the resident’s consent. On a specific date, during the 7:00 PM shift change narcotic count, staff identified that multiple doses of Percocet and Norco (hydrocodone-acetaminophen) were missing from the narcotic box on a single medication cart. Prior to this discovery, the assigned LPN had confirmed that the narcotic count was correct earlier in the day. The events leading to the deficiency included the LPN giving her medication cart narcotic keys to an RN while she left the area to perform a urine specimen collection. The LPN did not complete a narcotic count before or after transferring the keys, which was not in accordance with facility expectations for key control and chain of custody. When the LPN returned, she observed the medication cart in the nurses’ station and unlocked. The RN later confirmed that she had moved the cart into the nurses’ station but denied administering any medications during the time she had possession of the keys. During the subsequent 7:00 PM narcotic count, discrepancies were identified, and a search of the cart and nurses’ station did not locate the missing medications. Record review showed that four residents’ controlled medication logs required corrections to reflect missing tablets. One resident with dementia had an order for oxycodone-acetaminophen 5-325 mg every 12 hours as needed for pain; the narcotic log initially showed a remaining balance of 20 tablets after a documented administration, but was later corrected to 16 tablets to account for four missing tablets. A second resident with COPD had an order for oxycodone-acetaminophen 10-325 mg every eight hours as needed; the log was corrected from a remaining balance of five tablets to four, indicating one missing tablet. A third resident with dysphagia had an order for hydrocodone-acetaminophen 5-325 mg every 24 hours as needed; the log showed two tablets on hand after the resident returned from pass with no administrations documented, and was later corrected to zero, indicating two missing tablets. A fourth resident with type 2 diabetes mellitus with diabetic neuropathy had an order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed; the log was corrected from a remaining balance of eight tablets to seven, indicating one missing tablet. These discrepancies, combined with the unsecured cart and improper key transfer without counts, led to the determination that resident medications were not protected from misappropriation.
Failure to Prevent Elopement of Two Cognitively Impaired Wanderers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for two residents with known wandering and elopement risk. Both residents were ambulatory, frequently walked throughout the facility together, and were known to staff as wanderers. Each resident had a diagnosis of dementia with severe cognitive deficits documented on their MDS assessments, and both had Wander/elopement alarms (wander guard bracelets) in place and used daily. The facility’s elopement/wandering policy stated that residents who are incapable of adequately protecting themselves and unable to determine when they are at risk for harm by wandering out of the facility should be placed on the resident security system to ensure safety. On the day of the incident, video surveillance later reviewed by the Administrator showed that a visitor entered an exit door on the B Unit at approximately 6:20 PM. The two residents at risk for elopement approached the door, and the visitor held the door open, allowing them to walk out of the building. The residents were wearing wander guard bracelets, and when they exited, the door alarm sounded. A nurse responded immediately to the alarm, exited the facility, and went down the walkway but did not see the residents. Staff were then alerted that the residents were missing, and a facility-wide search was initiated. Staff interviews and the facility’s documentation confirmed that the residents had previously been observed walking together throughout the facility and approaching doors, including the exit door involved in the incident. The Administrator reported that review of the video showed the two residents had approached the same door together two or three times prior to the elopement event. Despite their known patterns of wandering, severe cognitive impairment, and prior door-approach behavior, the residents were able to exit the facility unnoticed and unsupervised when the visitor held the door open. Staff ultimately located the residents across a four-lane high-capacity highway approximately 528 feet from the exit door and returned them to the facility, where body audits and assessments documented no injuries and intermittent confusion. The State Agency determined that the facility’s failure to provide adequate supervision to prevent the elopement of these residents, who had exhibited exit-seeking behaviors, placed them and other residents at risk for wandering and elopement in a situation likely to cause serious injury, harm, impairment, or death and cited the facility at F689 with Immediate Jeopardy and Substandard Quality of Care. The residents’ medical records and elopement reports documented that both were confused, had impaired memory, and were identified as wanderers. One resident had a BIMS score of 3 and the other a BIMS score of 0, both indicating severe cognitive deficits. Progress notes and elopement reports recorded that staff were notified when the residents were not on the unit and could not be located, that all staff were engaged in searching, and that the residents were ultimately found outside and assisted back into the building. Interviews with CNAs and an LPN described hearing a Code W called, running outside, and seeing the residents across the street after they had crossed the four-lane highway. The DON acknowledged that the residents were always walking in the facility, often together, and that they had wandered to doors and looked out, and agreed that increased monitoring and not allowing visitors to have door codes could have prevented the residents from leaving the building.
Removal Plan
- Conducted a facility search.
- Notified police of missing residents.
- Director of Nursing interviewed staff and residents.
- Notified the Medical Director and residents’ families.
- Administrator and Director of Nursing checked the wander guard system and facility doors to ensure proper functioning.
- Returned Resident #1 and Resident #2 to the facility.
- Completed an incident report.
- Completed an emergency Quality Assurance meeting.
- Initiated in-service training for all staff on the elopement policy, including a quiz to validate comprehension, and required staff (including contract staff) to complete the in-service before working their next scheduled shift, with Administrator monitoring compliance.
- Responded immediately to the door alarm by sending staff outside to locate residents and notifying additional staff to assist with the search.
- Reviewed video surveillance and confirmed a visitor held the door open allowing residents to exit.
- Held an emergency Quality Assurance meeting with the Medical Director, Director of Nursing, Administrator, Regional Director, involved staff, and Infection Preventionist.
- Changed the main entry door code.
- Verified entrance door signage was in place instructing not to allow residents to exit unaccompanied.
- Identified residents at risk for elopement and ensured elopement bracelets/transmitters were functional and doors were locking appropriately.
- Reviewed care plans for residents at risk for elopement.
- Completed body audits on Resident #1 and Resident #2.
- Conducted audits verifying resident location, elopement risk, and wander guard bracelet function.
- Medical Records updated care profiles of residents at risk for wandering.
- Assistant Administrator began audits of all doors for function and security.
- Provided in-services on elopement policy and procedure, Resident Rights, and incident and accident reporting.
- Conducted elopement drills on each shift.
- Implemented monitoring systems to sustain compliance.
- Director of Nursing to monitor wander guard system checks three times weekly for four weeks or until substantial compliance is attained.
- Director of Nursing to monitor resident behavior for elopement attempts via incident reports, observations, and communications weekly for four weeks or until substantial compliance is attained.
- Quality Assurance Committee to meet for four weeks to review compliance with the plan of action, then continue routine Quality Assurance monitoring if no further concerns are noted.
- Administrator to hold follow-up Quality Assurance meetings monthly for two months then quarterly thereafter to ensure sustained compliance.
- Updated entry screening kiosk to include an additional reminder and attestation to ensure resident safety, requiring visitors to agree that no resident comes in or out with them and triggering a staff alert if the visitor refuses.
- Administration spoke directly with the visitor to confirm visitor policies and procedures.
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the building unattended. The resident had diagnoses including dementia with agitation and a BIMS score of three, indicating severe cognitive impairment. The resident had been readmitted from a geriatric psychiatric hospitalization and was known by the DON to have a history of wandering. Despite this, the interdisciplinary team had previously determined that the resident was not at risk for elopement, and no elopement interventions such as a wander guard were in place at the time of the incident. On the day of the event, a visitor observed the resident standing near the front door and exited the facility without realizing the resident followed him outside. Staff later became aware that the resident was missing, and an LPN assisted in locating the resident. A CNA ultimately found the resident outside on the front porch and returned the resident to the facility, with the investigation determining the resident had been outside unattended for approximately five minutes. Staff interviews confirmed that the resident ambulated in the halls and had not previously attempted to exit the building, and that the resident was only reassessed and provided with a wander guard after the incident.
Failure to Care Plan for Pressure Injuries and Treatment Orders
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with pressure injuries. The facility’s undated Care Plan Policy and Procedure stated that each resident’s care plan would remain current and inform staff of needs, strengths, goals, and approaches, and that a comprehensive person-centered care plan would be completed as needed. Record review showed that the resident was admitted with Type 2 Diabetes Mellitus with ketoacidosis without coma and, per the Discharge MDS with an ARD of 1/19/26, had a BIMS score of 12 indicating moderately impaired cognition. Section M of the MDS documented two unstageable pressure injuries presenting as deep tissue injuries (DTIs). Physician orders dated 12/10/25 directed treatment to right and left DTI pressure ulcers. Despite these documented DTIs and treatment orders, review of the resident’s comprehensive care plan revealed no care plan addressing the DTIs on the left and right heels, which was inconsistent with the physician orders. During interviews, two LPNs responsible for MDS and care plan completion confirmed that the care plan did not include the DTIs and stated that care plans are developed based on the MDS and physician orders, and that audits comparing orders to care plans are done periodically but this had been missed. The DON stated her expectation that the wound care nurse update the care plan with new wound care treatment orders. An RN reported she could update care plan interventions but had not been trained to develop a new focused care plan and had not added the physician’s DTI treatment orders to the care plan, and she was not aware it was her responsibility to do so.
Unsecured Controlled Medication Left Unattended and Lost
Penalty
Summary
The facility failed to prevent misappropriation of resident property when a controlled substance prescribed for a resident was left unattended and subsequently went missing. Facility policies on abuse and neglect defined misappropriation of resident property to include missing prescription medications or diversion of resident medications, including controlled substances, and the Medication-Controlled Substances policy required that only authorized licensed nursing and pharmacy personnel have access to controlled medications, that all controlled substances be stored in a locked cabinet or compartment, and that accurate accountability of all controlled drugs be maintained. Despite these policies, a pharmacy courier delivered thirty Hydrocodone/Acetaminophen 10-325 mg tablets for a resident with a left femur fracture, and the medication was signed for by an LPN but was not signed onto the narcotic accountability record, was not documented on the narcotic box package count, and could not be located. The resident, who was cognitively intact with a BIMS score of 15 and had a physician’s order for Hydrocodone/Acetaminophen, was later informed that the tablets delivered had been lost. Interviews revealed that one LPN received the blister pack of thirty Hydrocodone/Acetaminophen tablets from another LPN and placed it on the nurses’ station before leaving the area, leaving the controlled medication unattended. Both LPNs reported being in the medication room while the medication remained unattended at the nurses’ station. The DON reported being notified that the medication was missing and that an investigation confirmed the medication could not be located and had been left unattended, and the Administrator confirmed staff failed to ensure controlled medications were secured and accessible only to authorized personnel and that the facility was unable to determine the location of the missing medication.
Failure to Secure Controlled Drugs and Follow Refrigerated Storage Requirements
Penalty
Summary
The deficiency involves the facility’s failure to store and secure medications, including controlled substances, in accordance with professional standards and manufacturer instructions. For Resident #1, who was admitted with a left femur fracture and was cognitively intact with a BIMS score of 15, the physician ordered Hydrocodone-Acetaminophen 10-325 mg tablets. A facility investigation documented that a pharmacy courier delivered 30 tablets of this controlled medication, which were received and signed for by an LPN but were never documented in the narcotic count system and were later unable to be located. One LPN reported that after receiving the Hydrocodone-Acetaminophen from another LPN, she left the medication unattended at the nurses’ station while she completed other tasks instead of immediately securing it in the locked medication cart. The LPN who initially received the medication from the courier confirmed that the controlled medication had not been immediately secured in the locked cart following delivery. For Resident #3, who was admitted with heart disease and had a BIMS score of 10 indicating moderately impaired cognition, the physician ordered Lorazepam (Ativan) oral concentrate. The narcotic record showed that two containers of Lorazepam were signed into the narcotic record on the date of admission. Manufacturer prescribing information for the Lorazepam oral concentrate specified that it must be protected from light and stored refrigerated at 36–46°F. During a controlled drug count, surveyors observed that two bottles of Lorazepam oral concentrate for this resident were stored in the locked medication cart rather than in a refrigerator, despite the label instructions requiring refrigeration. One LPN confirmed the manufacturer’s storage instructions on the label but was unsure why the medication had not been refrigerated, and another LPN acknowledged awareness that the medication required refrigeration but confirmed it had been stored in the medication cart instead of the designated medication refrigerator.
Failure to Provide Required Involuntary Discharge Notice and Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of an involuntary discharge, including appeal rights, and to obtain a physician’s discharge order before refusing readmission of a resident following a hospital transfer. Facility policy titled “Transfer Form” stated that it is the policy of the facility to provide a completed and accurate transfer form to residents transferred or discharged from the facility, and the policy titled “Appealing a Transfer or Discharge Notice” stated that residents have the right to appeal transfer or discharge notices and, upon notice of transfer or discharge, will be provided with a statement of their right to appeal. Record review showed that the resident, admitted with hemiplegia and hemiparesis following cerebral infarction, left the facility by facility van to be admitted to a psychiatric hospital for evaluation. Progress notes dated several days after the transfer documented that the resident had been discharged from the facility due to aggressive behavior and that, per conversation with the psychiatric hospital, the Administrator and Social Services Director would assist in finding alternative placement and home health if needed. Documentation further indicated that, due to threats made, the facility stated it was unable to meet the resident’s needs and communicated with the resident’s family that the resident would not be allowed to return. During interview, the Administrator confirmed that neither the resident nor the family was provided a formal involuntary discharge notice or information on appeal rights and that no physician order for discharge could be located, acknowledging that the formal notice, appeal rights, and physician order should have been obtained prior to discharge.
Failure to Investigate and Resolve Ongoing Food-Related Grievances
Penalty
Summary
The facility failed to ensure that grievances voiced through the Resident Council regarding food quality and temperature were thoroughly investigated, addressed, and resolved. Resident Council minutes over multiple months documented repeated complaints that weekend food was "bad," tasted sweet, and that food was cold by the time it reached residents. Additional concerns included insufficient ice in water and tea, hard breakfast biscuits and toast, and cold grits. Although the facility’s grievance policy stated that residents and families could voice grievances without reprisal and that the facility would make prompt efforts to resolve grievances, there was no documentation that the initial complaint about weekend food quality was addressed, and subsequent complaints continued without evidence of thorough investigation or resolution. Resident Council Department Response Forms showed limited actions, such as placing food in containers to maintain temperature, conducting an in‑service for dietary staff, sending food out faster, and instructing staff to pass trays promptly, but there was no documentation of monitoring, follow‑up, or evaluation of whether these measures were effective. Residents interviewed, all cognitively intact per their MDS BIMS scores, consistently reported that the food remained cold and did not taste good, with one resident noting that staff would reheat food only if requested. The Dietary Manager acknowledged awareness of the complaints and stated he had spoken with weekend staff and made changes like replacing tray carts and providing guidance on food preparation, but confirmed there was no documentation of ongoing monitoring or additional interventions. Social Services and the Administrator both acknowledged awareness of the complaints and that additional follow‑up and resolution efforts should have occurred, yet no evidence of such follow‑up was present in the records.
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