Middleton Oaks Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Middleton Oaks Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF656Mar 31, 2026

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

• Actual harm, isolatedF688Mar 31, 2026

  Based on observation, interview, record review, and facility policy review the facility failed to provide services to maintain or improve Range of Motion (ROM) and prevent further decline for one (1) of three (3) resident reviewed for ROM limitations Resident #1. Findings Included:Record review of the facility policy Prevention of Decline in Range of Motion, date reviewed/revised 11/10/2025 revealed Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .Observation on 3/31/26 at 10:15 AM, revealed a foot splint lying in the chair in Resident #1's room. […]

• Actual harm, isolatedF656Mar 27, 2025

  Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a comprehensive care plan for personal hygiene (Resident #5, #12, #51), wound treatment (Resident #11), staff assistance with meals (Resident #42) and treatment for nausea and vomiting (Resident #75), for six (6) of 22 resident care plans reviewed. Findings include: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, revealed, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements .Develop a comprehensive plan of care for each… […]

• Actual harm, isolatedF684Mar 27, 2025

  Based on observation, staff interview, record review and facility policy review, the facility failed to ensure necessary care and services were provided for one (1) of 38 residents (Resident #75) reviewed for PEG (percutaneous endoscopic gastrostomy) tube management and PRN (as needed) medication administration. Specifically, nursing staff failed to administer Zofran 4 mg (milligrams) PRN for vomiting/gagging on multiple documented occasions, despite physician orders and clinical indications. […]

• No harm, potential for more than minimal, widespreadF726Mar 27, 2025

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