Middleton Oaks Health And Rehabilitation
MIDDLETON OAKS HEALTH AND REHABILITATION in WINONA, MS — inspection on September 18, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on the implementation of the facility's corrective actions on 8/16/25, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 8/18/25.
The SA validated on 9/18/25, through interview and record review that all corrective actions had been implemented as of 8/16/25, and the facility was in compliance as of 8/18/25, prior to the SA's entrance on 9/17/25.
Record review of the “admission Record” revealed that the facility admitted Resident #1 on 10/18/23 with a diagnosis of Hypertensive Disease without Heart Failure.
Record review of the “admission Record” revealed that the facility admitted Resident #2 on 6/9/23 with a diagnosis of Cerebral Infarction.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleton Oaks Health and Rehabilitation
627 Middleton Road Winona, MS 38967
SUMMARY STATEMENT OF DEFICIENCIES
Based on staff interview, record review and facility policy review, the facility failed to maintain complete and accurate medical records for one (1) of three (3) residents reviewed for post-operative care.
This deficient practice resulted in the omission of a physician-ordered post-operative appointment from the resident's medical record and contributed to the resident missing the appointment. (Resident #3).Findings Include Review of the facility policy titled Physician's Orders revealed Policy The center will ensure that all physician orders are accurately documented, promptly implemented, and authenticated in the resident's medical record in accordance with Center for Medicare and Medicaid (CMS) regulations and state requirements .
Record review of Resident #3's “After Visit Summary” (AVS) upon admission revealed an order for a post-operative visit on 5/6/25 at 1:00 PM with the Orthopedic Physician.
Record review of Resident #3's Order Summary Report revealed an entry for an appointment on 5/20/25 at 10:15 AM with the Orthopedic Physician, with an onset date of 5/6/25. No order was documented for the 5/6/25 post-operative appointment.
An interview with the Director of Nursing (DON) on 9/17/25 at 11:00 AM, revealed that Resident #3 did not attend the 5/6/25 orthopedic appointment because the order was not entered into the record.
The DON stated it is facility practice that the admitting nurse enters all admission orders, and verified the resident was admitted on the 3–11 shift.
The DON stated the 3–11 supervisor performed the admission and entered the orders, but the 5/6/25 appointment was missed.
She further stated that she and the Assistant Director of Nursing (ADON) review admission orders in their clinical meeting the following day, but acknowledged they missed the order as well.
The DON verified that the resident missed the 5/6/25 appointment due to the missed order.
Record review of the “admission Record” revealed that the facility admitted Resident #3 on 4/17/25 with a diagnosis of Acquired absences of left leg below the knee.
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