Middleton Oaks Health And Rehabilitation
MIDDLETON OAKS HEALTH AND REHABILITATION in WINONA, MS — inspection on March 31, 2026.
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 record review, interview, observation and facility policy review the facility failed to
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 functional decline.Interventions: Apply splint to right ankle after breakfast.
Provide passive stretch to right ankle after applying splint.
Remove splint to right ankle at lunchtime.
Apply splint to right ankle after supper.
Provide passive stretch to right ankle after applying splint.
Remove splint to right ankle at bedtime.
Date initiated 8/1/25.Observation on 3/31/26 at 10:15 AM, revealed the resident's ankle splint was not in use and was lying in a chair in the resident's room.Interview with Resident #1 on 3/31/26 at 10:17 AM, revealed she was unsure when the splint was last applied.An interview with the Physical Therapy Assistant (PTA) on 3/31/26 at 1:10 PM revealed the resident now had foot drop and the ankle splint could not be placed without additional therapy. PTA confirmed this was related to the splint not being applied daily as ordered.Interview with the Director of Nursing (DON) on 3/31/26 at 3:40 PM, revealed the care plan was used to inform staff how to care for the resident and verified staff failed to follow the care plan when they did not apply the ankle splint.
Record review of the admission Record revealed that the facility admitted Resident #1 on 1/16/25 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side.
Record review of Minimum Data Set Assessment (MDS) with and Assessment Reference Date (ARD) of 1/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating that the resident is cognitively impaired.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
255171 03/31/2026
Middleton Oaks Health and Rehabilitation 627 Middleton Road Winona, MS 38967
ROM and/or mobility, unless a decline is for a medical reason.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on
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. Resident #1's right hand was contracted into a fist with no hand roll in place.Interview with Resident #1 on 3/31/26 at 10:17 AM, revealed she was unsure of the last time staff had applied the splint to her foot and stated she had never had a hand roll.Interview with Licensed Practical Nurse #1 (LPN) on 3/31/26 at 10:30 AM, revealed she did not know why the splint was in the resident's room and stated the resident was not required to wear it.
She further verified the resident did not have a hand roll.
Record review of the Physician Order Summary revealed physician orders dated 7/29/25, to apply a splint to the right ankle after breakfast and after supper with passive stretching following application.
Record review of Occupational Therapy (OT) evaluation dated 2/1/25, revealed decreased ROM to the right upper extremity and recommendations for a resting hand splint and restorative splint and brace program upon discharge.
Further review of OT evaluation dated 7/31/25, recommended continuation of the contracture management and splinting program.
Record review of a Physician Order dated 4/24/25 revealed Apply splint to right hand after breakfast.
Provide passive stretch to right elbow, wrist, and hand after applying splint one time a day for decrease contractures.remove the splint before dinner.
Further review revealed an order dated 5/2/25 to discontinue the splint with a note per RP (responsible party) request.
States it is too painful for her mom to wear.Interview with the Occupational Therapist on 3/31/26 at 12:30 PM, revealed she had not been notified that the hand splint had been discontinued and stated that a hand roll should have been initiated when the splint was discontinued.
She further stated the resident's hand was now contracted into a fist.
Record review of Physical Therapy (PT) Discharge summary dated [DATE], revealed the resident's right ankle ROM improved during therapy and recommended a PODUS boot (a specialized orthopedic brace designed to treat foot drop) daily up to five (5) hours.Interview with the Physical Therapy Assistant (PTA) on 3/31/26 at 1:10 PM revealed the resident now had foot drop and the ankle splint could not be placed without additional therapy. PTA confirmed this was related to the splint not being applied daily as ordered.Interview with the Director of Nursing (DON) on 3/31/26 at 3:30 PM, verified the resident had physician orders for ankle splinting daily and stated the expectation was for staff to apply the splint to prevent decline in ROM.
The DON further verified the right-hand splint was discontinued without alternative interventions to prevent contracture.
Record review of the admission Record revealed that the facility admitted Resident #1 on 1/16/25 with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side.
Record review of Minimum Data Set Assessment (MDS) with and Assessment Reference Date (ARD) of 1/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating that the resident is severely cognitively impaired.