Midtown Oaks Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Midtown Oaks Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF919Jul 3, 2024

  Based on review of policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow residents to call for staff assistance, by failing to ensure that the call bell system was working. This failure put 15 of 22 residents reviewed who need to utilize their call bell for staff assistance in an Immediate Jeopardy situation. Findings include: The facility's policy regarding resident communication system and call lights, dated April 30, 2024, revealed that it was the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath area. […]

• Actual harm, isolatedF684Aug 22, 2024

  Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow a physician's recommendations for one of 45 residents reviewed (Residents 13) resulting in a deterioration of the wound with increased size, and there was no documented evidence that physician's orders were followed for two of 45 residents reviewed (Residents 12, 86). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that… […]

• Actual harm, isolatedF686Aug 22, 2024

  Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 4 pressure ulcer for one of 45 residents reviewed (Resident 13) resulting in a deterioration of the wound. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated June 29, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance from staff for care needs, and had a Stage IV pressure ulcer (a wound with full-thickness skin loss that extends through into the muscle, exposing the bone, tendon, or joint) upon admission. […]

• Actual harm, isolatedF689May 30, 2023

  Based on review of facility policies, clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, by failing to ensure that care-planned interventions were in place for one of seven residents reviewed (Resident 7), resulting in a fractured tibia and fibula (lower leg bones) and a fracture of the fibular head (leg bone under knee cap) for the resident. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety in the kitchen, in one of two pantries (second floor) and one of two refrigerators (third floor pantry) observed.Findings include: The facility policy regarding food storage, dated April 29, 2025, revealed that any food that has been opened must be labeled, dated and secured in such a way that the food item is not open to air, and that the facility would ensure a clean and sanitary environment. […]