Middleton Oaks Health And Rehabilitation
Inspection Findings
F-Tag F0602
F 0602
been removed from the cart by LPN #4 on 8/16/25.
Level of Harm - Minimal harm or potential for actual harm
Record review of the Order Summary Report revealed Resident #1 had an order for Norco 5-325 mg from 2/17/25 through 3/19/25.
Residents Affected - Few
Record review of the Physician Orders revealed Resident #2 had an order for Norco 7.5-325 mg from 1/13/25 through 8/18/25.
An interview with LPN #1 on 9/17/25 at 8:40 AM, revealed that narcotics are reconciled each shift by on-coming and off-going nurses, with additions or subtractions documented and witnessed. She stated that when she reconciled the cart on 8/16/25, she observed counts scratched through and a decrease from 34 to 31 without documentation of additions or removals. She reported the discrepancy to the DON immediately.
An interview with LPN #2 on 9/17/25 at 9:04 AM, confirmed that she reconciled the narcotics with LPN #4
on 8/16/25 and verified the number was changed to 31 and circled but could not explain the discrepancy.
She further stated that she sometimes did not check the Master List Controlled Drug form and acknowledged that Resident #1's discontinued narcotics remained on the cart.
An interview with the DON on 9/17/25 at 9:30 AM, revealed she was notified of the discrepancy on 8/16/25 at approximately 5:15 PM. She confirmed that narcotics were missing, and that Resident #1's discontinued Norco and Resident #2's active Norco were not accounted for. She further stated the missing Master List Controlled Drug form could not be located. She verified that LPN #4, the nurse on duty during the shift in question, refused to assist with the investigation and was suspended on 8/17/25 and terminated on 8/21/25.
An interview with the DON and Administrator on 9/17/25 at 2:30 PM, verified that a reconciliation and match back was completed on 8/16/25 of all narcotics and that corrective actions were initiated, including weekly audits implemented with continuation at least monthly and an in-service on narcotic security and misappropriation prevention.
A follow-up interview with the DON and Administrator on 9/18/25 at 8:40 AM, confirmed that the incident and investigation results were presented to the Quality Assurance Committee on 8/18/25, during which the facility policy was reviewed with no revisions made.
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Middleton Oaks Health and Rehabilitation
627 Middleton Road Winona, MS 38967
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
MIDDLETON OAKS HEALTH AND REHABILITATION in WINONA, MS inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WINONA, MS, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MIDDLETON OAKS HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.