Inspection Reports for
Middleton Oaks Health and Rehabilitation
627 Middleton Road, Winona, MS, 38967
Back to Facility Profile57 Reports
Inspection Report — Sep 2, 2026
Complaint Investigation
Date: Sep 2, 2026
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #3052535, CI MS #3075590, CI MS #3109657, CI MS #3107120, CI MS #3109709, and CI MS #3179879) at the facility from 9/1/26 through 9/2/26. The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiency F0684 for CI MS #3052535 and CI MS #3109657. No deficiencies were cited for the other complaint investigations.
Complaint Details
Six complaint investigations were conducted, with deficiencies cited for CI MS #3052535 and CI MS #3109657 related to quality of care. No deficiencies were cited for CI MS #3075590, CI MS #3107120, CI MS #3109709, and CI MS #3179879.
Findings
The facility failed to ensure adequate nursing assessment and evaluation for a resident who exhibited a significant increase in left lower-extremity pain, resulting in delayed identification of an acute displaced left femur fracture. The resident experienced prolonged severe pain for approximately six weeks, with repeated refusals of care due to pain and insufficient follow-up by nursing staff and providers.
Deficiencies (1)
F0684 - Quality of care. The facility failed to provide adequate nursing assessment and evaluation for Resident #2 who had increased left leg pain, resulting in delayed diagnosis of an acute displaced left femur fracture.
Report Facts
Deficiencies cited: 1
Complaint investigations: 6
Inspection Report — Apr 29, 2026
Complaint Investigation
Date: Apr 29, 2026
Visit Reason
The State Agency conducted a complaint investigation (CI) MS #2988764 at the facility on 4/29/26 regarding the allegation of physical environment.
Complaint Details
CI MS #2988764 regarding the allegation of physical environment was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm, with no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Apr 29, 2026
Follow-Up
Date: Apr 29, 2026
Visit Reason
On 4/29/26 the State Agency (SA) conducted an onsite revisit for the complaint survey completed on 3/31/26. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with requirements of the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Complaint Details
Complaint survey completed on 3/31/26; the facility was found in compliance upon revisit.
Findings
The State Agency determined the facility was in compliance and recommended the facility be placed back in compliance effective 4/21/26.
Report Facts
Deficiencies cited: 0
Inspection Report — Mar 31, 2026
Complaint Investigation
Date: Mar 31, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS# 2725825) at the facility on 3/31/26 due to concerns about failure to implement care plan and failure to provide services to prevent a decline in range of motion.
Complaint Details
Complaint Investigation (CI MS# 2725825) regarding failure to implement care plan and failure to provide services to prevent decline in range of motion; deficiencies were substantiated and cited.
Findings
Two deficiencies were cited related to failure to implement the comprehensive person-centered care plan and failure to provide services to maintain or improve range of motion, resulting in decline for one resident.
Deficiencies (2)
F0656 - The facility failed to implement the comprehensive person-centered care plan related to contracture management and splinting to prevent decline in range of motion for one resident.
F0688 - The facility failed to provide services to maintain or improve range of motion and prevent further decline for one resident, including failure to apply prescribed splints and provide alternative interventions.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 14, 2025
Complaint Investigation
Date: Nov 14, 2025
Visit Reason
On 11/14/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 09/18/25. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint survey completed on 09/18/25; the facility was found in compliance after corrective measures.
Findings
The facility was found to be back in compliance effective 10/17/25 with no deficiencies cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 18, 2025
Complaint Investigation
Date: Sep 18, 2025
Visit Reason
The State Agency conducted complaint investigations (CI) for CI #481277, CI #481280 and CI #2592974 at the facility from 9/17/25 through 9/18/25. The SA determined the facility was not in compliance with the Requirements of Participation in Medicare and Medicaid. F602 related to misappropriation was cited for CI# 2592974. The SA cited F842 related to resident records for CI #481277. The SA found no deficient practice for CI #481280.
Complaint Details
Complaint investigations were conducted for CI #481277, CI #481280, and CI #2592974. Deficiencies were cited for CI #2592974 (F602) related to misappropriation and CI #481277 (F842) related to resident records. No deficient practice was found for CI #481280.
Findings
Two deficiencies were cited related to misappropriation of narcotics and incomplete resident records. The facility failed to ensure residents were free from misappropriation of property and failed to maintain complete and accurate medical records, resulting in a missed post-operative appointment.
Deficiencies (2)
F0602 - Free from misappropriation/exploitation. The facility failed to ensure residents were free from misappropriation of narcotics when narcotics belonging to two residents were unaccounted for, including altered narcotic count sheets and missing controlled drug forms.
F0842 - Resident records - identifiable information. The facility failed to maintain complete and accurate medical records for one resident, resulting in the omission of a physician-ordered post-operative appointment and the resident missing the appointment.
Report Facts
Deficiencies cited: 2
Inspection Report — Sep 18, 2025
Complaint Investigation
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to investigate complaints related to misappropriation of residents' narcotics and incomplete medical records for post-operative care.
Complaint Details
The complaint investigation found substantiated issues of narcotic misappropriation affecting two residents and incomplete medical records affecting one resident, leading to a missed post-operative appointment.
Findings
The facility failed to ensure residents were free from misappropriation of property when narcotics belonging to two residents were unaccounted for. Additionally, the facility failed to maintain complete and accurate medical records for one resident, resulting in a missed post-operative appointment.
Deficiencies (2)
F 0602: The facility failed to protect residents from misappropriation of property when narcotics for two residents were unaccounted for due to altered narcotic count sheets and missing documentation.
F 0842: The facility failed to maintain complete and accurate medical records for one resident, resulting in the omission of a physician-ordered post-operative appointment and the resident missing the appointment.
Report Facts
Narcotic packages discrepancy: 3
Residents reviewed for misappropriation: 3
Residents reviewed for medical record accuracy: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Nurse on duty during narcotic discrepancy; refused to assist with investigation and was terminated |
| LPN #1 | Licensed Practical Nurse | Identified narcotic count discrepancy on 8/16/25 |
| LPN #2 | Licensed Practical Nurse | Reconciled narcotics with LPN #4 on 8/16/25 but could not explain discrepancy |
| Director of Nursing | Director of Nursing | Notified of narcotic discrepancy, confirmed missing narcotics, and verified corrective actions |
Inspection Report — Apr 30, 2025
Follow-Up
Date: Apr 30, 2025
Visit Reason
On 4/30/25 the State Agency conducted an onsite revisit for the annual survey and complaint investigation that was completed on 3/27/25. The information reviewed confirmed that the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back into compliance effective 4/24/25. No deficiencies were cited during this revisit survey.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 29, 2025
Life Safety
Date: Apr 29, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey conducted on 03/28/25 to confirm corrective measures and compliance with the Life Safety Code.
Findings
The facility was found to have implemented corrective measures and was placed back in compliance with the Life Safety Code effective 04/24/25.
Inspection Report — Mar 27, 2025
Annual Inspection
Date: Mar 27, 2025
Visit Reason
Annual recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity, safety, care plan implementation, medication administration, infection control, and documentation. Deficiencies included failure to provide privacy covers for catheter bags, improper feeding practices, inadequate call light accessibility, unsafe environment conditions, incomplete wound care documentation, failure to administer ordered medications, inadequate personal hygiene care, lack of staff training on Enhanced Barrier Precautions, and improper medication storage.
Deficiencies (12)
F 0550: The facility failed to honor residents' dignity by not providing privacy covers for urinary and biliary catheter drainage bags for multiple residents.
F 0558: Resident #71's call light was not within reach for multiple days, limiting the resident's ability to summon help.
F 0584: The facility failed to maintain a safe, clean, and homelike environment, including unresolved plumbing issues, damaged furniture, and unclean personal items for several residents.
F 0656: The facility failed to implement comprehensive care plans for personal hygiene, wound treatment, meal assistance, and medication administration for multiple residents.
F 0677: The facility failed to provide adequate assistance with activities of daily living, including grooming and nail care, for several residents.
F 0684: Resident #75 was not administered ordered anti-nausea medication on multiple occasions, resulting in vomiting and feeding intolerance.
F 0690: Resident #439 had an indwelling catheter without physician orders for catheter care, risking inadequate monitoring and care.
F 0726: Staff lacked education and training on Enhanced Barrier Precautions, resulting in failure to use required personal protective equipment during high-contact care activities.
F 0761: Resident #28's intravenous medication was left unattended on bedside table, posing a risk of unauthorized access.
F 0810: Resident #42 was not provided adaptive eating utensils or staff assistance as required, impairing her ability to eat independently.
F 0842: Resident #11's wound treatments were not documented for 12 days in March 2025, compromising continuity of care.
F 0880: The facility failed to implement an effective infection prevention and control program, including failure to use Enhanced Barrier Precautions during wound care and PEG tube handling, reuse of a single-use PEG tube declogger, and improper storage of a biliary drainage bag on the floor.
Report Facts
Residents present: 93
Undocumented wound treatments: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed lack of privacy covers on catheter bags and dignity issues |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed dignity issues and improper catheter bag privacy covers |
| Director of Nursing | Director of Nursing | Confirmed failures in wound care documentation, medication administration, and personal hygiene care |
| Wound Care Registered Nurse | Wound Care Registered Nurse | Performed wound care without Enhanced Barrier Precautions and confirmed lack of documentation |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Confirmed failure to administer ordered medication and lack of staff training on Enhanced Barrier Precautions |
| Administrator | Administrator | Acknowledged lack of staff education on Enhanced Barrier Precautions and failure to implement |
Inspection Report — Feb 5, 2025
Complaint Investigation
Date: Feb 5, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI) MS# 26580, CI MS# 26905, and CI MS# 27079 at the facility on 2/5/25.
Complaint Details
Complaint investigation numbers CI MS# 26580, CI MS# 26905, and CI MS# 27079 were conducted and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions of Aged or Infirm with no deficiencies cited.
Report Facts
Complaints investigated: 3
Inspection Report — Sep 4, 2024
Complaint Investigation
Date: Sep 4, 2024
Visit Reason
The State Agency conducted complaint investigation (CI MS# 26303 and CI MS# 26360) at the facility on 9/3/24.
Complaint Details
Complaint investigation CI MS# 26303 related to elopement and CI MS# 26360 related to quality of care and environment were both investigated and found to have no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. There were no deficiencies cited related to elopement or quality of care and environment.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 14, 2024
Complaint Investigation
Date: Aug 14, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS #25585) at the facility on 08/14/2024.
Complaint Details
Complaint number CI MS #25585 was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — May 13, 2024
Complaint Investigation
Date: May 13, 2024
Visit Reason
The State Agency conducted a complaint survey, MS CI# 24886, at the facility on 5/13/24.
Complaint Details
Complaint MS CI# 24886 was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. There were no deficiencies cited for MS CI# 20523 related to quality of care.
Report Facts
Complaint investigations: 1
Inspection Report — May 13, 2024
Follow-Up
Date: May 13, 2024
Visit Reason
The State Agency conducted a follow-up survey at the facility on 5/13/24, after a complaint survey with deficiencies 4/8/24 through 4/9/24. The SA recommends putting the facility back into compliance with the Medicare and Medicaid regulations for participation effective 5/9/24.
Findings
The facility was found to have deficiencies during the prior complaint survey and was surveyed again to verify compliance. The follow-up survey aimed to ensure the facility corrected the cited issues.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 9, 2024
Complaint Investigation
Date: Apr 9, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI) MS #23809 and CI MS #24538 at the facility on 04/08/24 through 04/09/24. The facility was found not in compliance related to CI #24538 for staffing and cited M225. The facility was in compliance related to CI MS #23809 for verbal abuse.
Complaint Details
Complaint Investigation (CI) MS #24538 was substantiated with deficiencies cited related to staffing. Complaint Investigation (CI) MS #23809 for verbal abuse was found to be in compliance with no deficiencies cited.
Findings
The facility failed to meet the minimum nursing staff ratio requirement of 2.80 hours per resident for multiple days reviewed, putting residents at risk for inadequate care. Staffing shortages were confirmed by interviews and record reviews, and the facility acknowledged the problem and had plans to address it.
Deficiencies (1)
M225 - The facility failed to meet the minimum nursing staff ratio requirement of 2.80 hours per resident for six out of eight days reviewed, resulting in staffing shortages that put residents at risk for not receiving adequate care.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 30, 2023
Follow-Up
Date: Nov 30, 2023
Visit Reason
The State Agency conducted a revisit to the annual survey at the facility on 11/30/23 to determine if the deficiencies cited on the 09/28/2023 survey were corrected.
Findings
The survey determined that the actions taken by the facility corrected the deficiencies cited on the 09/28/2023 survey. The facility was found to be back in compliance with Medicare and Medicaid requirements effective 11/22/2023.
Report Facts
Deficiencies cited: 0
Inspection Report — Nov 29, 2023
Complaint Investigation
Date: Nov 29, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #23628, CI MS#23205 and CI MS #23063) at the facility from 11/27/23 through 11/29/23. The survey investigated neglect, pressure sores, quality of care/resident safety, and quality of care/not groomed adequately with no deficiencies cited.
Complaint Details
Complaint Investigation CI MS #23628, CI MS#23205 and CI MS #23063 investigated neglect, pressure sores, quality of care/resident safety, and quality of care/not groomed adequately with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation. The facility remains out of compliance due to deficiencies cited on prior surveys dated 09/28/23 and 10/18/23.
Inspection Report — Oct 18, 2023
Complaint Investigation
Date: Oct 18, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI) MS# 23045 at the facility on 10/18/23 due to concerns about reporting of alleged violations.
Complaint Details
CI MS# 23045 involved allegations regarding failure to timely report a resident accident involving wheelchair transportation. Deficiency F0609 was cited for failure to timely report the incident, substantiating the complaint.
Findings
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 of four residents reviewed. The incident involved Resident #1 whose wheelchair tipped backward during transport, causing injury to his left shoulder and head.
Deficiencies (1)
F0609 - Reporting of Alleged Violations. The facility failed to report a resident involved accident in a timely manner to the State Agency, with the initial report delayed until four days after the incident.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 18, 2023
Complaint Investigation
Date: Oct 18, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report a resident-involved accident involving a wheelchair lift van to the State Agency.
Complaint Details
The complaint investigation was substantiated. The facility did not notify the Ombudsman or State Agency in a timely manner about the incident involving Resident #1's wheelchair tipping over during transport. The Former Director of Nursing was responsible for the delayed reporting.
Findings
The facility failed to complete timely reporting of an incident where Resident #1's wheelchair tipped over during transport, causing minor injury. Interviews and record reviews confirmed delayed reporting to the State Agency by the Former Director of Nursing.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities as required by policy and federal regulations.
Report Facts
Residents reviewed for wheelchair transportation safety: 4
Date/time of occurrence: Oct 5, 2023
Date survey completed: Oct 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Reported the incident of Resident #1's wheelchair tipping over during transport. | |
| Registered Nurse (RN) #1 | Received initial report of the incident and informed the Administrator, Former DON, MD, and NP. | |
| Former Director of Nursing (DON) | Responsible for reporting the incident to the State Agency; delayed reporting confirmed. | |
| Administrator | Confirmed Former DON was responsible for timely reporting and that reporting was delayed. |
Inspection Report — Sep 28, 2023
Routine
Date: Sep 28, 2023
Visit Reason
Routine inspection of Middleton Oaks Health and Rehabilitation to assess compliance with regulatory requirements including resident rights, care plans, infection control, and medication management.
Findings
The facility was found deficient in multiple areas including failure to honor resident privacy, inadequate follow-up on resident grievances, failure to provide a safe and clean environment, incomplete PASARR screening, failure to implement comprehensive care plans, improper medication storage, and inadequate infection prevention and control practices.
Deficiencies (9)
F 0550: The facility failed to honor a resident's dignity by posting private care information on Resident #81's door, violating privacy requirements.
F 0565: The facility failed to follow up on grievances from Resident Council meetings regarding timely answering of call lights for Residents #39 and #66.
F 0576: The facility failed to deliver mail to residents on Saturdays, affecting 10 residents in the Resident Council and potentially all residents.
F 0584: The facility failed to provide a safe, clean, and homelike environment as evidenced by dirty wheelchairs, torn armrests, dirty floors, scuffed paint, gouged walls, broken drawers, and broken windows.
F 0645: The facility failed to complete a Level 1 PASARR screening for Resident #81, violating preadmission screening requirements.
F 0656: The facility failed to implement comprehensive care plans for Residents #32, #33, #57, and #248, resulting in unmet grooming and personal hygiene needs.
F 0677: The facility failed to provide adequate Activities of Daily Living (ADL) care including nail care for Resident #32, shaving for Residents #33, #57, and #248, and showering for Resident #248.
F 0761: The facility failed to ensure medications were not left unsecured in Resident #4's room, risking resident safety and medication misuse.
F 0880: The facility failed to prevent infection spread by improper catheter bag placement, use of contaminated equipment, inadequate cleaning of isolation rooms, and use of ineffective disinfectants against Candida Auris affecting Residents #8, #54, #75, and #81.
Report Facts
Residents present during inspection: 96
Residents in Resident Council meeting: 10
Residents affected by mail delivery issue: 10
Residents reviewed for PASARR: 3
Residents with deficient care plans: 4
Residents observed for ADL care deficiencies: 4
Residents sampled for medication storage: 28
Residents affected by infection control deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Confirmed privacy violation with sign posted on Resident #81's door | |
| Registered Nurse (RN) #2 | Confirmed privacy violation with sign posted on Resident #81's door | |
| Director of Nursing (DON) | Confirmed privacy violation, call light grievance follow-up failure, dirty wheelchair, medication storage issues, and infection control deficiencies | |
| Activity Director | Confirmed call light grievances and mail delivery issues | |
| Certified Nursing Assistant (CNA) #2 | Assigned to Resident #33 and #57, confirmed grooming deficiencies | |
| Certified Nursing Assistant (CNA) #4 | Performed catheter care with infection control breaches | |
| Licensed Practical Nurse (LPN) #3 | Confirmed Resident #8 was in contact isolation and catheter bag infection control issue | |
| Registered Nurse (RN) #1 | Confirmed medication storage and administration issues for Resident #4 | |
| Housekeeping #1, #2, #3 | Described cleaning procedures and disinfectant use | |
| Environmental District Manager | Confirmed disinfectant used was ineffective against Candida Auris | |
| Administrator (ADM) | Acknowledged facility deficiencies and lack of awareness of Candida Auris cases | |
| MDS Nurse | Responsible for care plan development and confirmed care plan deficiencies |
Inspection Report — Sep 28, 2023
Annual Inspection
Date: Sep 28, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey in the facility from 9/25/23 through 9/28/23. The SA determined the facility was not in compliance with Medicare and Medicaid regulations for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations due to multiple deficiencies including failure to honor resident dignity, inadequate follow-up on grievances, failure to deliver mail on Saturdays, unsafe and unclean environment, incomplete PASARR screening, incomplete care plans, inadequate ADL care, improper medication storage, and infection control lapses.
Deficiencies (9)
F0550 - Resident rights were violated when a sign with private care information was posted on Resident #81's door, compromising dignity and privacy.
F0565 - The facility failed to follow up on grievances related to call light response times for Residents #39 and #66, despite repeated concerns raised in Resident Council meetings.
F0576 - The facility failed to deliver mail to residents on Saturdays, violating residents' rights to receive mail promptly.
F0584 - The facility failed to maintain a safe, clean, comfortable, and homelike environment as evidenced by dirty wheelchairs, damaged furniture, gouged walls, and stained floors.
F0645 - The facility failed to complete a required Level 1 PASARR screening for Resident #81 prior to admission.
F0656 - The facility failed to implement comprehensive care plans for Residents #32, #33, #57, and #248, resulting in unmet needs such as unshaven residents and untrimmed nails.
F0677 - The facility failed to provide adequate ADL care including shaving, nail care, and showers for Residents #32, #33, #57, and #248.
F0761 - The facility failed to ensure medications were properly stored and labeled, as inhalers were left unsecured in Resident #4's room without assessment or orders for self-administration.
F0880 - The facility failed to maintain effective infection prevention and control practices including missing biohazard containers in isolation rooms, failure to disinfect rooms with appropriate chemicals for Candida Auris, allowing a urinary catheter bag to touch the floor, using contaminated oxygen tubing on a tracheostomy humidifier, and using a soiled washcloth during catheter care.
Report Facts
Deficiencies cited: 9
Inspection Report — Sep 27, 2023
Life Safety
Date: Sep 27, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Aug 22, 2023
Complaint Investigation
Date: Aug 22, 2023
Visit Reason
On 08/22/23 the State Agency (SA) conducted a desk review of the information that was provided related to the complaint survey completed on 07/20/23.
Complaint Details
Complaint CI MS#26995 was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that the facility be placed back in compliance effective 08/20/23.
Inspection Report — Aug 16, 2023
Complaint Investigation
Date: Aug 16, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #22360) at the facility on 8/16/2023. The SA investigated Nutrition and Hydration with no deficiencies cited.
Complaint Details
Complaint number CI MS #22360 investigated Nutrition and Hydration; no deficiencies were cited and the complaint was determined to be unsubstantiated.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid during this complaint investigation.
Report Facts
Complaint investigations: 1
Inspection Report — Jul 20, 2023
Complaint Investigation
Date: Jul 20, 2023
Visit Reason
The State Agency conducted Complaint Investigations at the facility for seven complaints from 7/17/23 through 7/20/23. The SA investigated multiple complaints including misappropriation of property, call lights not answered timely, staffing, residents left wet, body odor, physical environment, abuse, neglect, and services not provided. Deficiencies were cited related to staffing, physical environment, neglect, and abuse.
Complaint Details
The complaint investigation involved seven complaints including misappropriation of property, call lights not answered timely, staffing issues, residents left wet, body odor, physical environment concerns, abuse, neglect, and services not provided. Deficiencies were cited related to neglect, staffing, physical environment, and abuse.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies included failure to protect residents from neglect, failure to report alleged violations timely, failure to implement comprehensive care plans, failure to provide quality care and treatment to prevent and heal pressure ulcers, and failure to ensure competent nursing staff. Registered Nurse #2 failed to provide wound care treatments on multiple dates and was terminated. Several residents did not receive wound or pressure sore treatments as ordered.
Deficiencies (6)
F0600 - Free from Abuse and Neglect. The facility failed to protect four residents from neglect as Resident #1 did not receive wound treatments on multiple dates and Residents #2, #3, and #4 did not receive pressure sore treatments on 7/17/23.
F0609 - Reporting of Alleged Violations. The facility failed to report an incident of neglect involving Resident #1 to the appropriate licensing agencies in a timely manner.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement the comprehensive care plan for four residents as wound and pressure sore treatments were not provided as ordered.
F0684 - Quality of Care. The facility failed to provide needed care and services in accordance with professional standards for Resident #1 who did not receive wound treatments on multiple dates.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to ensure three residents received necessary treatment and services for pressure ulcers as treatments were not provided on 7/17/23.
F0726 - Competent Nursing Staff. The facility failed to ensure nursing staff had the competencies and skills to provide care as ordered for four residents, resulting in missed wound and pressure sore treatments.
Report Facts
Deficiencies cited: 6
Complaints investigated: 7
Inspection Report — Jul 20, 2023
Complaint Investigation
Date: Jul 20, 2023
Visit Reason
The inspection was conducted due to complaints regarding neglect and failure to provide wound care treatments to residents at Middleton Oaks Health and Rehabilitation.
Complaint Details
The complaint investigation substantiated neglect related to failure to provide wound care treatments to four residents on multiple dates. The new treatment nurse admitted to not performing treatments and failing to communicate this. The facility also failed to report the neglect incident to licensing agencies as required.
Findings
The facility failed to provide wound care treatments to four residents on multiple dates, including 7/8/23, 7/9/23, 7/10/23, and 7/17/23. The new treatment nurse admitted to not performing the treatments and failed to communicate this. The facility also failed to report the neglect incident to appropriate licensing agencies. Several residents confirmed their wound care was not done as ordered.
Deficiencies (6)
F 0600: The facility failed to protect four residents from neglect by not providing wound and pressure sore treatments on specified dates.
F 0609: The facility failed to timely report an incident of neglect involving Resident #1 to the appropriate licensing agencies.
F 0656: The facility failed to develop and implement a complete care plan for four residents, resulting in missed wound and pressure sore treatments on specified dates.
F 0684: The facility failed to provide appropriate treatment and care according to orders for Resident #1, who missed wound treatments on multiple dates.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Residents #2, #3, and #4, who missed pressure sore treatments on 7/17/23.
F 0726: The facility failed to ensure nurses and nurse aides had appropriate competencies to care for residents, resulting in missed wound and pressure sore treatments for four residents on specified dates.
Report Facts
Residents affected: 4
Missed wound care days for Resident #1: 4
BIMS scores: 15
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding wound care failures and investigation. | |
| Administrator | Interviewed regarding wound care failures and failure to report neglect. | |
| RN #2 | New treatment nurse who admitted to not performing wound care treatments on multiple dates. | |
| Licensed Practical Nurse (LPN) #1 | Reported dressings were not dated and confirmed missed wound care on 7/17/23. |
Inspection Report — Jun 15, 2023
Complaint Investigation
Date: Jun 15, 2023
Visit Reason
The State Agency conducted a Complaint Investigations (CI) at the facility for four complaints, CI MS #21378, CI MS #21502, CI MS #21807 and CI MS #21707 from 6/13/2023 through 6/15/2023. During the survey, the SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid.
Complaint Details
The SA investigated CI MS #21378 for Misappropriation of Property and cited F602. The SA investigated CI MS #21807 for Misappropriation of Property and did not cite any deficiencies. The SA investigated CI MS #21707 for Neglect, Quality of Care/Treatment and did not cite any deficiencies. The SA investigated CI MS #21502 for Quality of Care/Treatment: Staffing, Nursing Services and Pharmaceutical Services and did not cite any deficiencies.
Findings
F0602 - The facility failed to protect a resident from misappropriation of property when a Certified Nurse Aide withdrew money from a resident's bank account and deposited it into her own account without authorization.
Deficiencies (1)
F0602 - The facility failed to protect a resident from misappropriation of property when a Certified Nurse Aide withdrew money from a resident's bank account and deposited it into her own account without authorization.
Report Facts
Deficiencies cited: 1
Complaints investigated: 4
Inspection Report — Jun 15, 2023
Complaint Investigation
Date: Jun 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of a resident's property by a Certified Nurse Aide (CNA).
Complaint Details
The complaint was substantiated. The CNA admitted to taking $25 from Resident #1's account and depositing it into her own account, confirmed by interviews and video evidence.
Findings
The facility failed to protect a resident from misappropriation of property when a CNA withdrew $25 from a resident's account and deposited it into her own account. The CNA admitted to the act during an investigation and video interview.
Deficiencies (1)
F 0602: The facility failed to protect residents from wrongful use of belongings or money. A CNA withdrew $25 from a resident's account without consent and deposited it into her own account.
Report Facts
Amount misappropriated: 25
Residents reviewed for misappropriation: 4
Brief Interview for Mental Status (BIMS) score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) | Employee who misappropriated $25 from Resident #1's account | |
| Director of Nurses (DON) | Interviewed regarding the investigation and findings | |
| Administrator | Interviewed regarding evidence of misappropriation | |
| Human Resources staff | Conducted investigation and interviewed involved parties | |
| Attorney General investigator | Conducted interview with CNA and obtained admission on video |
Inspection Report — May 2, 2023
Routine
Date: May 2, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a required seven-day period, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 20, 2023
Complaint Investigation
Date: Apr 20, 2023
Visit Reason
The State Agency conducted a complaint survey, MS CI #20782 at the facility on 4/20/23 regarding Quality of care/not groomed, Quality of care/Responsible Party and Medical Doctor notification and resident assessment.
Complaint Details
Complaint MS CI #20782 involved allegations of Quality of care/not groomed, Quality of care/Responsible Party and Medical Doctor notification and resident assessment. The complaint was determined to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid for the complaint and no deficiencies were cited.
Report Facts
Complaints investigated: 1
Inspection Report — Jan 24, 2023
Complaint Investigation
Date: Jan 24, 2023
Visit Reason
The State Agency conducted a complaint survey, MS #20363, on 1/24/23.
Complaint Details
Complaint MS #20363 was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Oct 13, 2022
Complaint Investigation
Date: Oct 13, 2022
Visit Reason
The State Agency conducted a complaint survey CI MS #19619 on 10/13/22 regarding allegations about physical environment/proper medical equipment, quality of care/left soiled for extended amount of time, and quality of care/treatments with call bells not answered timely.
Complaint Details
Complaint CI MS#19619 alleged issues with physical environment, medical equipment, quality of care including residents left soiled and call bells not answered timely. The complaint was not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate the complaint CI MS#19619 and found no deficiencies. The facility was determined to be in compliance with Medicare and Medicaid requirements.
Report Facts
Complaints investigated: 1
Inspection Report — Jul 28, 2022
Complaint Investigation
Date: Jul 28, 2022
Visit Reason
The State Agency conducted a complaint survey MS #19409 and MS #19422 from 7/26/22-7/28/22. The SA did not substantiate the complaint of MS #19409 with an allegation of Quality of Care/Treatment and MS #19422 with allegations of Resident to Resident Abuse and Resident Rights.
Complaint Details
Complaint MS #19409 alleged Quality of Care/Treatment and MS #19422 alleged Resident to Resident Abuse and Resident Rights. Both complaints were not substantiated and no deficiencies were cited.
Findings
During the survey, the SA determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Jun 8, 2022
Complaint Investigation
Date: Jun 8, 2022
Visit Reason
The State Agency conducted complaint survey for CI MS# 18703 and CI MS #18718 at the facility from 06/06/2022 to 06/08/2022 along with an Employee Vaccination section of the Infection Control survey.
Complaint Details
Complaint numbers CI MS# 18703 and CI MS #18718 were investigated; allegations related to injury of unknown origin and abuse were not substantiated and no deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards for the Institutions for the Aged or Infirm. The SA did not substantiate noncompliance with CI MS #18703 related to Injury of unknown origin or CI MS #18718 related to Abuse and no deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 7, 2022
Complaint Investigation
Date: Feb 7, 2022
Visit Reason
A Complaint Investigation (CI) #18322 was conducted by the State Agency on 2/7/22 regarding an allegation against Quality of Care/Treatment.
Complaint Details
CI #18322 with the allegation against Quality of Care/Treatment was unsubstantiated with no deficiencies.
Findings
The facility was found to be in compliance with the Mississippi Long Term Care regulations and no deficiencies were cited.
Report Facts
Complaint Investigations: 1
Inspection Report — Nov 16, 2021
Annual Inspection
Date: Nov 16, 2021
Visit Reason
On 11/16/21 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey conducted on 10/7/21.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and is recommended to be placed back in compliance effective 11/15/21.
Inspection Report — Oct 7, 2021
Routine
Date: Oct 7, 2021
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation standards in the facility's kitchen and food storage areas.
Findings
The facility failed to prevent the likelihood of foodborne illness due to expired and unlabeled food items in the refrigerator and inadequate cleaning of the ice machine, which had black substance contamination on the ice and interior walls.
Deficiencies (1)
F 0812: The facility failed to ensure all food items were properly labeled and dated, with expired cream cheese and unlabeled sliced cheese, lettuce, and shredded vegetables found in the kitchen cooler. The ice machine was not cleaned as scheduled, with black substance contamination observed on ice and interior surfaces, posing a risk of foodborne illness.
Report Facts
Date of last ice machine cleaning: Jul 13, 2021
Black spots on ice machine: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff #1, #2, #3, #4 | Confirmed expired and unlabeled food items and black substance on ice machine | |
| Facility Administrator | Confirmed observation of black substance in ice machine and responsibility for maintenance | |
| Maintenance Staff #1 | Confirmed ice machine cleaning schedule and filter replacement frequency |
Inspection Report — Oct 7, 2021
Annual Inspection
Date: Oct 7, 2021
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/04/2021 through 10/07/2021.
Findings
The facility was found to have deficiencies related to food safety, including out of date and unlabeled food items in the refrigerator and an unclean ice machine with black substance contamination, posing a risk of foodborne illness to residents.
Deficiencies (1)
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to prevent the likelihood of foodborne illness by having out of date and unlabeled food items in the refrigerator and black substance contamination inside the kitchen ice machine.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 7, 2021
Annual Inspection
Date: Oct 7, 2021
Visit Reason
The State Agency conducted an annual recertification along with a complaint, MS #18043 at Winona Manor from 10/4/21 to 10/7/21. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid. The SA did not substantiate MS #18043 for quality of care related to resident safety/falls, with no citations related to the complaint.
Complaint Details
Complaint MS #18043 was investigated but not substantiated for quality of care related to resident safety/falls, with no citations related to the complaint.
Findings
F0812 - The facility failed to prevent the likelihood of foodborne illness by having out of date and unlabeled food items in the refrigerator and failing to clean the ice machine, which had black substance on the ice and interior walls. Dietary and maintenance staff confirmed the issues and the facility initiated corrective actions including education and quality monitoring.
Deficiencies (1)
F0812 - The facility failed to prevent the likelihood of foodborne illness as evidenced by out of date and unlabeled food items in the refrigerator and black substance on the ice and interior walls of the kitchen ice machine.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 5, 2021
Life Safety
Date: Oct 5, 2021
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found deficient in maintaining portable fire extinguishers according to NFPA standards, with 12 of 14 extinguishers overdue for the required 12-year inspection. The Administrator and Maintenance Supervisor acknowledged the findings during the exit interview.
Deficiencies (1)
K0355 - Portable fire extinguishers were not selected, installed, inspected, and maintained in accordance with NFPA standards; 12 of 14 extinguishers were overdue for the 12-year inspection.
Report Facts
Deficiencies cited: 1
Inspection Report — Sep 9, 2021
Complaint Investigation
Date: Sep 9, 2021
Visit Reason
A Complaint Investigation (CI) for Complaint #17954 was conducted on 9/9/21 with allegations against Administration/Personnel.
Complaint Details
Complaint #17954 involved allegations against Administration/Personnel and was unsubstantiated with no deficiencies cited.
Findings
The allegations were unsubstantiated with no deficiencies cited. The facility was found in compliance.
Report Facts
Complaint count: 1
Inspection Report — May 18, 2021
Complaint Investigation
Date: May 18, 2021
Visit Reason
The State Agency conducted complaint investigations (CI MS #17679, CI MS #17257, and CI MS #17655) from 5/17/21 through 5/18/21.
Complaint Details
Complaint investigations CI MS #17679, CI MS #17257, and CI MS #17655 were conducted and not substantiated; no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. No citations were related to the complaints investigated.
Report Facts
Complaint investigations: 3
Inspection Report — Nov 20, 2020
Routine
Date: Nov 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 10/18/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Nov 20, 2020
Routine
Date: Nov 20, 2020
Visit Reason
State Agency conducted a COVID-19 Infection Control (FIC), along with complaint investigations MS #17222, MS #17064, and MS #17104 from 10/18/2020 to 10/20/2020.
Complaint Details
Complaint investigation MS #17222 was substantiated with deficiencies cited (F0656 and F0657). Complaints MS #17064 and MS #17104 were not substantiated and had no deficiencies cited.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. Deficiencies were cited for complaint MS #17222 related to care plans, while no deficiencies were cited for the COVID-19 focused infection control survey or the other complaints.
Deficiencies (2)
F0656 - The facility failed to develop and implement adequate care plans as required.
F0657 - The facility failed to ensure care plans were comprehensive and updated.
Report Facts
Deficiencies cited: 2
Inspection Report — Oct 20, 2020
Routine
Date: Oct 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 10/18/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Oct 20, 2020
Routine
Date: Oct 20, 2020
Visit Reason
State Agency (SA) conducted a COVID-19 Infection Control (FIC), along with complaint(s), MS #17222, MS #17064, and MS #17104 from 10/18/2020 to 10/20/2020. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid. SA substantiated CI MS #17222 and cited F-656 and F-657 related to care plans. The SA did not substantiate MS #17064 related to staffing and MS#17104 related to quality of care, with no deficiencies cited. No deficiencies were cited related to the COVID-19 Focused Infection (FIC) survey.
Complaint Details
Complaint investigation MS #17222 was substantiated with deficiencies cited related to care plans (F656 and F657). Complaints MS #17064 and MS #17104 were not substantiated and had no deficiencies cited.
Findings
The facility failed to develop and implement comprehensive person-centered wound care plans for two residents and failed to review and revise comprehensive wound care plans for two other residents. Care plans for wounds were missing or not updated to reflect current wound status and treatment orders.
Deficiencies (2)
F0656 - The facility failed to develop and implement a comprehensive person-centered wound care plan for two of four residents reviewed with wounds, including missing care plans for a suspected deep tissue injury and an unstageable wound.
F0657 - The facility failed to review and revise comprehensive wound care plans for two of four residents reviewed with wounds, including failure to update wound staging and treatment orders in care plans.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 26, 2020
Routine
Date: Aug 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/26/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 26, 2020
Routine
Date: Aug 26, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16623, CI MS #16797, CI MS #16949) was conducted by the State Agency (SA) on 8/26/2020.
Complaint Details
CI MS #16623: The complaint investigation was unsubstantiated with no deficiencies cited for Quality of Care related to Resident Meds not Given According to Physicians Orders and Falsification of Records. CI MS #16797: The complaint investigation was unsubstantiated with no deficiencies cited for Resident Abuse. CI MS #16949: The complaint investigation was unsubstantiated with no deficiencies cited for Resident Abuse Related to Verbal Abuse.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Aug 3, 2020
Routine
Date: Aug 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/3/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 3, 2020
Routine
Date: Aug 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/3/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Jun 18, 2020
Routine
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/18/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 18, 2020
Routine
Date: Jun 18, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/18/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Nov 21, 2019
Complaint Investigation
Date: Nov 21, 2019
Visit Reason
The State Agency conducted a complaint survey investigating CI MS#16364 and CI MS#16386 on 11/19/19-11/21/19. Concerns identified in complaint #16363 were related to possible quality of care and treatment, and concerns in complaint #16386 were related to resident rights.
Complaint Details
Complaint CI MS#16364 involved possible quality of care and treatment and was not substantiated. Complaint CI MS#16386 involved resident rights and was not substantiated.
Findings
The concerns in both complaints were not substantiated, and no deficiencies were cited. The facility was determined to be in substantial compliance with Medicare and Medicaid participation requirements.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 21, 2019
Complaint Investigation
Date: Feb 21, 2019
Visit Reason
A complaint investigation was conducted on February 21, 2019 in the facility.
Complaint Details
Complaint investigation CI MS #15665, CI MS #15683 and CI MS #15684 were conducted. The investigation was substantiated and unsubstantiated with no deficiencies cited.
Findings
The investigation was substantiated and unsubstantiated with no deficiencies cited.
Report Facts
Complaints investigated: 3
Inspection Report — Jan 28, 2019
Complaint Investigation
Date: Jan 28, 2019
Visit Reason
The State Agency (SA) conducted a complaint survey (MS #15620) and a revisit of the annual survey on 1/25/19 and 1/28/19. The complaint was substantiated for missing controlled substances and failure to ensure accurate acquisition, availability, and reconciliation of controlled substances.
Complaint Details
Complaint MS #15620 substantiated for missing controlled substances and failure to ensure accurate acquisition, availability, and reconciliation of controlled substances.
Findings
The facility failed to ensure controlled medications were acquired, secured, reconciled, and available for administration for four residents (#6, #7, #8, and #9). Resident #7 did not have Tramadol replaced or available for 18 days. Resident #6 had a Synthroid tablet taped into the Tramadol card. Residents #7, #8, and #9 had missing controlled medications that were signed in but not logged or accounted for. The facility's policies and procedures for controlled substances were not followed, and staff failed to properly document and reconcile medications.
Deficiencies (1)
F0755 - The facility failed to ensure controlled medications were acquired, secured, reconciled, and available for administration for four residents. Resident #7 did not have Tramadol replaced for 18 days, Resident #6 had a Synthroid tablet taped into the Tramadol card, and Residents #8 and #9 had missing medications not accounted for. Policies and procedures for controlled substances were not followed.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 20, 2018
Annual Inspection
Date: Dec 20, 2018
Visit Reason
An annual recertification survey was conducted from 11/18/18 through 11/20/18 by the State Survey Agency. The State Agency determined the facility failed to meet Medicare and Medicaid requirements for participation.
Findings
The facility was found to have multiple deficiencies including failure to provide baseline care plans to residents, failure to include residents in care planning, failure to perform glucose monitoring and administer insulin correctly, failure to serve food in a sanitary manner, failure to follow infection control precautions, and failure to meet essential electrical system requirements.
Deficiencies (6)
F0655 - Baseline Care Plan. The facility failed to review and provide the baseline care plan to the resident for one of five new admissions reviewed (Resident #60).
F0657 - Care Plan Timing and Revision. The facility failed to include the resident in the care planning process for one of 21 care plans reviewed (Resident #60).
F0684 - Quality of Care. The facility failed to perform glucose monitoring for two residents and administer insulin doses as prescribed for one resident (Residents #3 and #60).
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to serve food in a sanitary manner by touching ready-to-eat foods with bare hands during dining room observations.
F0880 - Infection Prevention & Control. The facility failed to prevent the possible spread of infection by not following transmission-based precautions for one resident on contact isolation (Resident #24).
K0918 - Electrical Systems - Essential Electric System. The generator failed to transfer power to the facility within the required 10 seconds, transferring in 17 seconds.
Report Facts
Deficiencies cited: 6
7 CMS Surveys
CMS Survey — Jun 15, 2023
Jun 15, 2023
CMS Survey — Jul 20, 2023
Jul 20, 2023
CMS Survey — Oct 18, 2023
Oct 18, 2023
CMS Survey — Sep 18, 2025
Sep 18, 2025
CMS Survey — Oct 7, 2021
Oct 7, 2021
CMS Survey — Sep 28, 2023
Sep 28, 2023
CMS Survey — Mar 27, 2025
Mar 27, 2025
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