Oaks - Bethany Skilled Nursing, The
OAKS - BETHANY SKILLED NURSING, THE in VIDALIA, GA — inspection on August 19, 2025.
Found 3 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
Review of the Quarterly MDS assessment dated [DATE] for R14 revealed Section C (Cognitive Patterns), a BIMS score of 12 out of 15 which indicated moderate cognitive impairment.During observations on 7/30/2025 at 10:33 am, 8/6/2025 at 10:46 am and on 8/19/2025 at 12:00 pm, two thick white tablets were observed sitting on RA's overbed table, which was positioned in front of her, while she was lying in bed, in her room.
During the observations, RA stated the tablets were for gas relief, and that the nurses had given them to her, and she took them after meals.
Review of RA's clinical record revealed a physician's order, dated 6/7/2025, for two, 80 milligram (mg) chewable Gas Relief tablets to be administered four times a day as needed for a diagnosis of GERD.
Review of the care plan for RA revealed no evidence that RA was care planned for self-administration of medication or for medications to be kept at bedside.
Review of the Self-Administration of Medication evaluation form dated 6/10/2025 revealed that RA was assessed as not wanting to self-administer medications and that staff would give medications.Following the observation on 8/19/2025 at 12:00 pm of medication in RA's room, Licensed Practical Nurse (LPN) BB was interviewed and observed the medication in RA's room at 12:10 pm.
She confirmed the medication was Gas Relief tablets and stated that she had not given any Gas Relief tablets to RA that day. LPN BB stated that she only gave them to RA when she asked, and that she did not ever leave any medication in the room.
During an interview on 8/19/2025 at 3:00 pm the Director of Health Services (DHS) confirmed that the medication should not have been left in RA's room.
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
115705 08/19/2025
Oaks - Bethany Skilled Nursing, The 1305 East North Street Vidalia, GA 30475
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R8 revealed Section B (Hearing, Speech, Vision) indicated highly impaired vision, Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated severe cognitive impairment and Section GG (Functional Abilities and Goals) indicated the need for assistance with Activities of Daily Living (ADL) care.Review of progress notes for R8 dated 6/25/2025 at 2:43 pm revealed, a nurse note entry that documented R8's roommate reported that the resident was on the floor. R8 was observed lying on her back on the right side of the bed, near the air conditioner unit. An abrasion was noted to her forehead.
The nurse note entry also documented that neurological checks were initiated and were within normal limits, with R8 being alert, oriented to person and confused as per usual for the resident. A floor mat was placed on the floor at bedside to prevent further occurrences.
Review of the care plan with problem start date of 4/7/2020 revealed R8 was at risk for falls related to impaired mobility, weakness, cognitive deficits, impaired vision, and psychotropic medication use.
Following the fall on 6/25/2025, the fall risk care plan was updated to include an intervention of a fall mat to bedside, dated 6/25/2025.During observations on 8/14/2025 at 2:27 pm, 8/18/2025 at 1:18 pm, and 8/19/2025 at 12:15 pm, R8 was lying in bed, in her room.
There was no fall mat on the floor on either side of her bed, as care planned.
During an interview on 8/19/2025 at 2:10 pm, when questioned about whose responsibility it was to implement a new intervention following a fall, the Administrator responded that it could be any one of the staff, but it would be the unit manager's responsibility.
Cross reference to F-F689
115705 08/19/2025
Oaks - Bethany Skilled Nursing, The 1305 East North Street Vidalia, GA 30475
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R8 revealed Section B (Hearing, Speech, Vision) indicated highly impaired vision, Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated severe cognitive impairment and Section GG (Functional Abilities and Goals) indicated the need for assistance with Activities of Daily Living (ADL) care.Review of progress notes for R8 dated 6/25/2025 at 2:43 pm revealed, a nurse note entry that documented R8's roommate reported that the resident was on the floor. R8 was observed lying on her back on the right side of the bed, near the air conditioner unit. An abrasion was noted to her forehead.
The nurse note entry also documented that neurological checks were initiated and were within normal limits, with R8 being alert, oriented to person and confused as per usual for the resident. A floor mat was placed on the floor at bedside to prevent further occurrences.Further review of progress notes for R8 dated 6/26/2025 revealed, a Patient at Risk (PAR) note entry that documented the interdisciplinary team (IDT) met and reviewed R8's recent fall.
The PAR note included that a fall mat was placed at the bedside to reduce the risk of injury related to falls.However, during observations on 8/14/2025 at 2:27 pm, 8/18/2025 at 1:18 pm, and 8/19/2025 at 12:15 pm, R8 was lying in bed, in her room, with no fall mats on the floor on either side of her bed.
During an interview on 8/19/2025 at 2:33 pm, the Director of Health Services (DHS) stated that R8's fall mat was in her room, but it was behind the chair.
The DHS stated that the housekeeper may have forgotten to put it back down after she cleaned the room.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.