Middleton Oaks: Neglected Splints Caused Permanent Harm - MS
The resident, identified only as Resident #1 in inspection records, was admitted to Middleton Oaks Health and Rehabilitation on January 16, 2025, after a cerebral infarction that left her with hemiplegia and hemiparesis on her right dominant side. A stroke of that nature affects everything: a person's ability to grip, to walk, to use the limbs they've relied on their entire lives. The only tool left to slow that loss is consistent, disciplined therapy. She wasn't getting it.
Her BIMS score, a standardized measure of cognitive function, was 5. That places her in the category of severely cognitively impaired. She could not advocate for herself. She could not demand that staff apply her splints. She could not remember, when an inspector asked her on the morning of March 31, the last time anyone had put the ankle splint on her foot. She said she had never had a hand roll.
She was right about the hand roll. The occupational therapist confirmed it.
A physician had ordered the ankle splint applied twice daily, after breakfast and after supper, with passive stretching each time. That order was dated July 29, 2025. The physical therapy assistant told inspectors on March 31 that the splint had not been applied daily as ordered, and that the resident now had foot drop, a condition in which the muscles that lift the front of the foot weaken or fail entirely. The PTA confirmed the foot drop was directly related to the missed applications. The ankle splint could no longer be placed without additional therapy.
The hand had its own history of neglect. An occupational therapy evaluation from February 2025 had flagged decreased range of motion in the right upper extremity and recommended a resting hand splint along with a restorative splinting program. By April, a physician had ordered the hand splint applied after breakfast each day, with passive stretching to the right elbow, wrist, and hand. That order lasted eight days. On May 2, 2025, it was discontinued at the request of the resident's responsible party, who said it was too painful for her mother to wear.
That discontinuation might have been reasonable. What happened next was not.
The occupational therapist told inspectors she had never been notified that the hand splint was stopped. She said that when a splint is discontinued, a hand roll should have been started to prevent the hand from contracting. Nobody started one. Nobody told her. By the time she spoke with inspectors at 12:30 in the afternoon on March 31, she confirmed what was already visible in the room: the resident's hand had contracted into a fist.
A Licensed Practical Nurse interviewed that same morning said she did not know why the ankle splint was even in the room and told inspectors the resident was not required to wear it. The physician orders, dated seven months earlier, said otherwise.
The Director of Nursing, interviewed at 3:30 that afternoon, verified that daily ankle splinting orders existed and said the expectation was for staff to apply the splint to prevent decline. She also verified that the hand splint had been discontinued without any alternative intervention to prevent contracture.
Middleton Oaks had a written policy on this. Its Prevention of Decline in Range of Motion policy, reviewed and revised as recently as November 2025, stated that residents who enter without limited range of motion will not experience a reduction unless their clinical condition makes it unavoidable. Resident #1 entered with limitations already present. The policy required the facility to prevent those limitations from getting worse. The inspection classified what happened to her as actual harm.
She came to Middleton Oaks already fighting to keep function in a body her stroke had partially taken from her. The therapy notes show she made progress. Her ankle range of motion improved during physical therapy. The discharge summary recommended the PODUS boot daily, up to five hours. That recommendation sat unfilled.
The foot splint was in the chair. Her hand was a fist. And the occupational therapist who might have caught it months earlier had never been told the program changed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Middleton Oaks Health and Rehabilitation from 2026-03-31 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Middleton Oaks Health and Rehabilitation
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Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
MIDDLETON OAKS HEALTH AND REHABILITATION in WINONA, MS was cited for neglect violations during a health inspection on March 31, 2026.
A stroke of that nature affects everything: a person's ability to grip, to walk, to use the limbs they've relied on their entire lives.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at MIDDLETON OAKS HEALTH AND REHABILITATION?
- A stroke of that nature affects everything: a person's ability to grip, to walk, to use the limbs they've relied on their entire lives.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in WINONA, MS, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MIDDLETON OAKS HEALTH AND REHABILITATION or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 255171.
- Has this facility had violations before?
- To check MIDDLETON OAKS HEALTH AND REHABILITATION's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.