Oaks - Athens Skilled Nursing, The

Based on observations, staff interview, and review of the facility policy titled, Labeling, Dating, and Storage, the facility dietary staff failed to ensure prepared food items were properly labeled and dated. Dietary staff also failed to ensure nutrition supplements were properly dated to indicate when to use by. The deficient practice affected all 136 facility residents who were all receiving an oral diet Findings include:Review of the facility policy titled Labeling, Dating, and Storage revised 11/11/2022 revealed under Procedure: 1. Food and beverage items will have an identifying label as well as a received dated and opened date, as applicable; for items prepare onsite, a use by date will also be indicated.Observation on 02/20/2026 at 9:15 AM of the 600 hall kitchenette revealed the kitchen had refrigerated pull out drawers that contained three rectangle shaped steam table pans. Two pans contained two-ounce containers of pre-portioned salad dressings, and one pan contained four-ounce cartons of nutrition supplements. Continued observation revealed that there were no labels or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policy titled, Cleaning Procedures: Major Equipment, the facility's dietary staff failed to ensure two of three kitchenette freezers were free from frost build-up which could lead to food contamination. Findings include:Review of the facility policy titled Cleaning Procedures: Major Equipment reviewed 10/23/2025 revealed under Procedure: under Walk in Refrigerator and Walk in Freezer, Daily:1. Keep freezer elements free of frost and ice build-up.Observation on 02/20/2026 at 9:20 AM of the kitchenette for the 500, 700, and 800 halls revealed a small freezer sitting on the countertop. The freezer had three shelves, and the middle shelf was fully covered with frost that was an inch thick. Continued observation revealed ice cream cups were sitting within the frost.During an interview on 02/20/2026 at 9:20 AM, the Dietary Manager (DM) confirmed that there was frost build-up on the middle shelf of the small freezer and confirmed the ice cream cups were within the frost build-up. The DM stated that the freezer was cleaned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility's policy titled, Resident Independent Self-Administration and Medication Assistance of Medications, the facility failed to assess one of 46 sampled residents (R) (R13) for self-administration of medication. This deficient practice created the potential for accidental ingestion, improper dosing, allergic reaction, or misuse of medication.Findings Include:Review of the facility policy titled Resident Independent Self-Administration and Medication Assistance of Medications, reviewed 02/16/2026, revealed under section titled Policy Statement, Residents who have the cognitive and functional capacity to safely engage in the self-administration of medications with or without staff assistance or supervision shall be allowed to store their own medications securely and self-administer medications if they so desire. As stated under section titled, Procedure, self-administering of medications by a resident is permitted only upon the specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of the facility policy titled Medication Storages in Healthcare Centers the facility failed to properly lock and secure two of six medication carts (medication cart 600 hall and medication cart 800 hall).Findings Include: Review of the facility policy titled Medication Storage in Healthcare Centers revised 11/11/2025 revealed under the Policy Statement that medications and biologicals are stored securely and properly in accordance with manufacturer recommendations or supplier guidance. Under the Procedure section, the policy states: Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observation on 02/17/2026 at 11:10 AM revealed Licensed Practical Nurse (LPN) AA entered resident room [ROOM NUMBER] (on 800 hall) while his medication cart remained unattended in the hallway. The medication cart was observed unlocked with no licensed staff present at the cart. When asked about the unlocked cart, LPN AA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policy's titled Transmission -Based Isolation Precautions, Enhanced Barrier Precautions, and the Procedure: Catheter Care, the facility failed to maintain an effective infection prevention and control program to prevent possible cross contamination. Specifically, facility failed to decrease the risk of transmission of infection related to one staff member not properly changing N-95 mask when exiting Transmission Based Precautions (TBP) room; one nurse not performing hand hygiene during catheter care, not using personal protective equipment during catheter care in an Enhanced Barrier Precaution (EBP) room, and not properly cleaning the tip of the catheter tubing after emptying the bedside drainage bag for one resident R52 of ten residents with a catheter. The deficient practice had the potential to spread infection throughout the facility. The facility census was 112. Findings: 1. Review of the facility policy titled Transmission -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility policy's titled, Oxygen Safety and Storage , Respiratory Equipment Changeouts, and the Procedure: Transferring a Resident Using a Mechanical Lift, the facility failed to ensure an environment free of accident hazards related to the handling and storage of Oxygen cannisters. In addition, the facility failed to use a mechanical lift device according to facility procedure and the manufacturer recommendation when transferring R100 via mechanical lift. The facility census 112. Findings include: 1. Review of the facility policy titled, Oxygen Safety and Storage revised 5/9/2023, documented the policy statement as the facility will ensure that Oxygen is administered and stored safely within the healthcare centers or outside storage areas. Procedure: Safety: Number 3. Do not fasten an oxygen tank to a patients/resident's bed. Tanks in use must either be installed on a stable, wheeled dolly or on an oxygen tank stand.Storage .Number 3. Oxygen tanks that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to provide sufficient nursing staff to provide for the needs of 3 out of 122 residents (R251, R114 and R718) in a timely manner. This failure had the potential to cause resident care needs to be delayed. Findings: 1. R251 was admitted to the facility on [DATE] and discharged on 1/4/2025. Her diagnoses were unspecified fracture of right femur and multiple fractures of pelvis without disruption of pelvic ring. Review of R251's discharge Minimum Data Set (MDS) assessment dated [DATE] indicated a BIMS of 15. Mood severity score of two. No behaviors and independent for most activities of daily living (ADLs) and always incontinent of bowel and bladder with presence of surgical wound. Review of care plan for R251 dated 1/2/2025 included risk for complication related to recent orthopedic surgery, requires assistance for all activities of daily living related to weakness, injury, and debility. She was care planned for urinary and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations, interviews and review of the facility policy , titled Coronavirus - COVID-19 Infection Prevention and Control Practices, the facility failed to implement an effective Infection Control Program (ICP) to prevent the spread of infections, including COVID-19 virus by not ensuring all staff wore a mask and self- screened for COVID-19 prior to entering the facility. The census was 97. Findings include: Review of a facility policy titled, Coronavirus - COVID-19 Infection Prevention and Control Practices, revised 10/27/20, revealed, All locations are required to setup screening stations at the main entrance to screen partners, vendors, and visitors for the following: - Travel to area where there are ongoing outbreaks of Coronavirus (COVID-19) (out of the country, beaches, and high case areas) - Contact with someone who has or is suspected to have COVID-19 - Symptoms of COVID. The policy also indicated, Should any partner present with all the above risk factors, the partner conducting the screening will: 1) Have the partner wait in the lobby area, and 2)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to ensure an allegation of abuse was reported immediately to the Administrator for one resident (R) (R#25), of three sampled residents. Findings include: A review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, revised 10/27/20, revealed, It is the policy of [corporation] and its affiliated entities (collectively, the 'Organization') to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as 'abuse, neglect, mistreatment, and exploitation'). The Organization and its partners should assure that best efforts are made to prevent any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, interviews , and review of the policy titled, Mandatory COVID-19 and Influenza Vaccination Policy, the facility failed to ensure one of 140 staff members was fully vaccinated or had a medical or religious exemption on file. Findings include: Review of a facility policy titled, Mandatory COVID-19 and Influenza Vaccination Policy, revised 4/1/22, revealed, This policy requires vaccination against COVID-19 and Influenza among all partners (employees) of the Organization. The goal is to protect - to the greatest extent possible - our partners, residents, guests, patients, and clients; their families; and the broader community from COVID-19 infection and the Influenza virus as we all do our part to survive this worldwide pandemic. The policy also indicated, All partners must: (a) be 'fully vaccinated' or (b) obtain an approved exemption from the Organization as a medical or religious accommodation. Partners receiving the COVID-19 vaccination are also required to receive any subsequent vaccine shots to become 'fully vaccinated.' For example, partners who receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.