Oaks - Athens Skilled Nursing, the

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, interviews, and review of the policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report a significant medication error for one of three sampled residents (R1), with actual harm occurred on 9/14/2024 when R1 was administered the wrong medications and was admitted to the Intensive Care Unit for higher level of care and monitoring. In addition, the facility failed to report allegations of sexual abuse to the State Survey Agency within the required time frame for two of three residents (R) (R7 and R8) when R8 was found in R7's room receiving oral gratification. [...]

Inspectors wroteBased on record review, interviews, and review of the policy titled Care Plans, the facility failed to follow the comprehensive person-centered care plan related to potential for decreased cardiac and aortic stenosis for one of 12 sampled residents (R) (R1). Actual harm occurred on 9/14/2024 when R1 was allegedly administered the wrong medications and was admitted to the Intensive Care Unit for higher level of care and monitoring. On 10/2/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Interim Director of Health Services, and Licensed Practical Nurse Unit Manager were informed of the Immediate Jeopardy (IJ) on 10/2/2024 at 12:03 pm. [...]

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to ensure that one resident (R) (R1) was free from a significant medication error which resulted in actual harm, requiring a transfer to the hospital and admitted to Intensive Care Unit on 9/14/2024. On 10/2/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Interim Director of Health Services, and Licensed Practical Nurse Unit Manager were informed of the Immediate Jeopardy (IJ) on 10/2/2024 at 12:03 pm. [...]

Inspectors wroteBased on record review, interviews, review of the Administrator Job Description and Director of Health Services Job Description, and review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility Administration failed to use its resources effectively and efficiently resulting in the failure to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to ensure resident (R) R1 was free from significant medication error resulting in actual harm on 9/14/2024, requiring transfer to hospital and admission to Intensive Care Unit (ICU). In addition, Administration failed to report the alleged medication error incident as well as an allegation of sexual abuse between R7 and R8 to the State Survey Agency (SSA) in a timely manner. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.