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Oaks Health Ctr: Fall Causes Femur Fractures - GA
Despite this clear requirement, the certified nursing assistant was performing bed linen changes alone....
Latest reports, citations, and penalties from CMS data
Despite this clear requirement, the certified nursing assistant was performing bed linen changes alone....
When inspectors contacted the listed physician, **the doctor stated the facility was not one where he sees residents**....
During the inspection, surveyors observed a nurse aide exiting a COVID patient's room wearing only a blue surgical mask after performing close-contact care....
This violation was classified as causing "minimal harm or potential for actual harm" but affected many residents throughout the facility....
The May 16, 2025 inspection revealed that on May 2, staff lost track of a 53-year-old resident with documented cognitive impairment and wandering behaviors....
## **Facility's Inadequate Response Exposed** Federal inspection records reveal significant gaps in how administrators handled the abuse allegation....
For residents receiving antibiotics for life-threatening infections like sepsis, proper medication delivery is crucial for treatment effectiveness....
When the attending physician ordered vital signs to be checked every four hours for 72 hours, nursing staff documented measurements at only 9:34 a.m....
The most concerning incident occurred on March 14 at 5:18 am when Licensed Practical Nurse BB left Medication Cart A unlocked outside the nurse station....
**Multiple nurses admitted to throwing used fentanyl patches directly into regular trash cans** without proper supervision or disposal procedures....
This violation directly contradicted physician orders designed to prevent choking and aspiration risks....
The violation was severe enough to trigger the highest level of enforcement action available to federal regulators....
The resident required Enhanced Barrier Precautions (EBP) due to having a pressure ulcer on the left buttock and being incontinent of bowel and bladder....
The facility received the citation following a complaint investigation completed on August 1, 2024....
Healthcare providers rely on these records to evaluate treatment effectiveness and adjust pain management plans....
The resident, who had difficulty swallowing and required assistance with meals, was prescribed a specific daily fluid goal of 1500-1800 milliliters....
The violations encompassed critical documentation gaps across multiple areas of resident care....
Another resident in a persistent vegetative state also had catheter tubing on the floor....
The facility's wound nurse discovered two new pressure injuries during routine care....
Federal regulations require nursing homes to investigate all allegations of abuse and take immediate protective action....