Mid-Town Oaks Post-Acute

In the surveyor’s words

From the most serious findings on record at Mid-Town Oaks Post-Acute, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 14, 2023

  46995 Based on observation, interview, and record review, the facility failed to provide treatment for one of 27 sampled residents (Resident 15) when Resident 15 did not receive preventative treatment (low air loss mattress- a mattress designed to distribute body weight over a large surface, used to help prevent skin breakdown) to prevent pressure ulcer (PU-injury to the skin and underlying tissue from prolonged pressure on the skin). This failure resulted in Resident 15 developing a Stage 4 (full thickness skin loss, wound can extend to muscle and bone) pressure ulcer to her sacrococcyx area (tailbone area). […]

• Actual harm, isolatedF689Oct 26, 2022

  Based on interview and record review, the facility failed to provide adequate supervision and assistance for one resident (Resident 1), who required two-person assistance for bed mobility, for a census of 85. This failure resulted in Resident 1 having an avoidable fall with injury, a left femur (thigh bone) fracture. Findings: During a review of Resident 1's medical records, the medical records indicated Resident 1 was admitted to the facility in early 2018, with diagnoses that included functional [CONDITION(S)] (inability to move with or without spinal damage) and [CONDITION(S)] (inability of a person to communicate effectively with others due to damage in a specific area of the brain). […]

• Actual harm, isolatedF686Sep 7, 2022

  Based on interview and record review, the facility failed to implement measures for the prevention of pressure ulcers for one resident (Resident 1) of two sampled residents when, Resident 1 developed a stage 3 pressure ulcer (an ulcer that has extended through dermis [second layer of skin] into the fatty subcutaneous [below the skin] tissues) on her coccyx (tailbone). This failure resulted in Resident 1 acquiring a preventable pressure ulcer and a delay in recovery. Findings: According to the Resident Face Sheet, Resident 1 was admitted in early March 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Jul 18, 2022

  Based on observation, interview, and record review, the facility failed to adequately supervise and prevent abuse for two of four sampled residents (Resident 1 and Resident 2) when Resident 2 sexually abused Resident 1. This failure had the potential to cause physical harm and emotional distress to Resident 1. Findings: Resident 1 was admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Minimum Data Set (MDS - an assessment tool), dated 9/15/20, documented her BIMS (a brief screening that aids in detecting cognitive impairment) score was 0 which indicated she had severe cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF921Jan 12, 2024

  Based on observation, interviews, and record review the facility failed to ensure the residents' shower room on the second-floor was sanitary. This failure decreased the facility's potential to provide residents with a sanitary bathroom and a homelike environment for a census of 35. Findings: During an observation on 1/12/24 at 10:06 a.m., in the shower room on the second-floor, the following was observed: Black and brown colored substance around the shower drain. Black and brown colored substances in the grout between tiles on the floor and walls. Missing grout in between tiles. Cracked, broken and missing tiles. During an interview on 1/12/24 at 10:14 a.m. with Resident 3, when asked about the cleanliness of the second-floor shower room, Resident 3 stated, It's disgusting. […]