Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Oaks during CMS and state inspections, most recent first.
A facility failed to maintain several resident rooms in a safe, clean, and homelike condition as required by its preventive maintenance policy. One room contained a bed with a broken footboard and sharp exposed material that had been present for months, while other rooms had cracked and taped windows with exposed headers, holes in walls, loose baseboards, stained and rusted ceiling tiles and tracking, floor stains, a missing bathroom door, and rusty door jambs. The Maintenance Supervisor and Maintenance Director acknowledged multiple oversights, including not entering issues into the TELS maintenance system and lacking routine room inspection or replacement plans, despite leadership expectations that all staff and leaders promptly report and monitor environmental repair needs. These deficiencies were documented as increasing the risk of infection and injury and not supporting a safe, clean, homelike environment.
Incomplete Care Plan for Antidepressant Use: A resident with moderate cognitive impairment, anxiety, bipolar disorder, muscle weakness, and urinary retention was receiving an antipsychotic, an antidepressant, and an opioid, but the care plan did not address antidepressant use. Physician orders for fluoxetine and trazodone included monitoring instructions for side effects and mood changes, and the RN MDS Coordinator and DON confirmed the care plan was missing this required information.
Medication Administered Contrary to Physician Order: A resident with a g-tube, dysphagia, and anticoagulant therapy orders received Eliquis via g-tube mixed in 15 ml of water instead of the ordered 60 ml of water or D5W. RN AA confirmed the discrepancy during observation, and RN BB and the DON stated that nurses are to follow the physician’s special instructions on the order.
The facility failed to ensure food safety by not properly labeling, dating, and storing food items, leading to potential food-borne illness risks. Observations revealed expired and unlabeled food in the refrigerator, incorrect dates on frozen chicken, and a leak in the freezer causing ice buildup on food boxes. The Dietary Manager and RD confirmed these issues, acknowledging the need for proper food handling and storage.
A facility failed to apply a physician-ordered neck brace for a resident with multiple vertebral fractures. Despite documentation indicating compliance, observations showed the resident without the brace on two occasions. A CNA confirmed the resident should wear the brace when out of bed, highlighting a discrepancy between records and actual practice.
Failure to Maintain Safe and Homelike Resident Rooms and Furnishings
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms, as required by its own preventive maintenance policy. The policy states that preventive maintenance schedules are to be developed and implemented to ensure the building and equipment are maintained in a safe and operable manner. Despite this, surveyors observed in one room that the bed footboard on the patient side had a broken area with exposed particles for an extended period. The resident in that room reported that maintenance was aware of the issue and that the footboard had been broken for four months. The Maintenance Supervisor later confirmed the presence of a sharp exposed particle on the footboard and stated he could not replace the bed due to a lack of another electric bed, and although he reported ordering a replacement part, he had no receipt and was unsure how long the footboard had been broken. Additional environmental deficiencies were identified in several other rooms. One room had a cracked window with tape placed over the cracked areas on both the top and bottom panes, and the window header was exposed. The Maintenance Supervisor stated that rocks from landscaping had cracked the window and that tape was applied to keep the crack from spreading, but he admitted the damage had never been entered into the TELS electronic maintenance system and called this an oversight. Another room had a hole in the wall and a baseboard coming off the wall under the window next to one of the beds; these conditions were observed on multiple days. The Maintenance Supervisor confirmed the hole and loose baseboard, explained that a bed had run into the wall, and reported he was not aware of the damage. Further observations showed that another room had stained and discolored ceiling tiles and tracking, including dark black and brown stains above the beds and rusty brown stains on the ceiling tracking, as well as a brown stain on the floor extending from the dresser under the window to the closet. The Maintenance Director confirmed these stains and acknowledged the ceiling tiles needed to be replaced, stating he did not have a routine plan to replace ceiling tiles or tracking and was not aware of the condition, describing it as an oversight. In yet another room, surveyors observed a loose baseboard between the exterior door and bathroom entrance, a missing bathroom door, and a brown rusty stain along the bathroom door jamb on repeated visits. The Maintenance Director confirmed the loose baseboard, rusty stain, and missing bathroom door, explaining the door had been removed because the resident could not access the bathroom and that the room was set up for two residents. He stated he did not have a scheduled plan to routinely check rooms and that repairs were addressed only when reported through the TELS system. The DON and Administrator both reported that all staff and leaders are responsible for entering repair needs into TELS and that leaders are to evaluate the environment daily, but the observed conditions showed that multiple issues had not been identified or entered into the system. These deficiencies increase the risk of infection and injury and do not support a safe, clean, and homelike environment.
Incomplete Care Plan for Antidepressant Use
Penalty
Summary
The facility failed to develop or implement a comprehensive, person-centered care plan for one resident, R3. The facility policy titled Patient's Plan of Care required each patient to have a person-centered comprehensive care plan addressing medical, physical, mental, and psychosocial needs while honoring preferences and goals. Review of R3's Quarterly MDS dated 03/26/2026 showed a BIMS score of 09, indicating moderate cognitive impairment, and listed diagnoses including anxiety, bipolar disorder, muscle weakness, and urinary retention. The MDS also showed that R3 was receiving an antipsychotic, an antidepressant, and an opioid. Review of R3's care plan dated 01/29/2026 showed that antidepressant use was not addressed. Physician orders dated 12/18/2025 and 01/20/2026 included fluoxetine 40 mg daily for bipolar depression and trazodone 100 mg at bedtime for insomnia, along with orders for antidepressant medication use that directed staff to observe for side effects such as dry mouth, blurred vision, constipation, urinary retention, hypotension, appetite changes, headache, insomnia, and weight changes, as well as sadness, negative comments, depressed mood, rejection of care, and withdrawal. The RN MDS Coordinator confirmed on 04/15/2026 that R3's care plan did not address antidepressant use and stated that antidepressants are required to be included in the care plan. The DON also stated on 04/16/2026 that residents prescribed psychotropic medications, antidepressants, and other high-risk medications should have these reflected in their care plans.
Medication Administered Contrary to Physician Order
Penalty
Summary
The facility did not ensure that medication was administered as ordered by the medical provider for one resident, R7, who had diagnoses including hypertension, cerebral infarction due to thrombosis of the right middle cerebral artery, gastrostomy status, anxiety disorder, gastrostomy infection, and dysphagia. R7’s care plan identified the need for a feeding tube related to dysphagia and included interventions to check placement and patency of the feeding tube before feeding or medication administration, as well as to administer anticoagulants as ordered and monitor for signs of active bleeding. A physician order dated 03/13/2026 directed that Eliquis (apixaban) 2.5 mg be given via g-tube twice daily and that the tablet may be crushed and suspended in 60 ml of water or D5W before immediate delivery through the g-tube. During observation, RN AA crushed medications separately and administered them separately for R7, mixing Eliquis in 15 ml of water instead of the ordered 60 ml of water or D5W. RN AA confirmed the order specified the larger volume and stated she should follow the order. RN BB and the DON stated that medications can have special instructions in the physician order and that nurses are to follow those orders.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper labeling, dating, and storage of food items. During an initial kitchen observation, several food items in the walk-in refrigerator were found to be either expired or not properly labeled and dated, including an open carton of cottage cheese and peeled hard-cooked eggs. Additionally, trays of shredded cooked meat and a container of soup were not labeled or dated. In the walk-in freezer, a large container of frozen chicken pieces had incorrect dates posted. These issues were confirmed by the Dietary Manager, who acknowledged that the expired food items should have been discarded and that all food items should have been properly labeled and dated. Further observations revealed a leak in the walk-in freezer, causing ice to form on the tops of cardboard boxes of food stored below the leak. A box of garlic knot bread rolls was found with the lid ajar and ice on top, indicating exposure to the air and water leak. The Dietary Manager and Registered Dietitian were unaware of the improperly secured bread rolls and confirmed that the food should have been properly sealed. They also acknowledged the presence of the leak and the need to move items away from it until repairs were made. These deficiencies had the potential to lead to food-borne illness among the facility's residents.
Failure to Apply Physician-Ordered Neck Brace
Penalty
Summary
The facility failed to apply a physician-ordered neck brace for a resident, identified as R48, who was admitted with multiple fractures, including an unspecified displaced fracture of the fourth cervical vertebra. The resident's electronic medical record indicated that the neck brace was to be worn whenever the resident was out of bed. However, observations on March 30, 2025, revealed that the resident was seen without the neck brace on two separate occasions, once in the dining room and once in the facility entrance area. Despite the Treatment Administration Record (TAR) indicating that the neck brace was applied as ordered, a Certified Nurse Aide (CNA) confirmed that the resident was supposed to wear the neck brace anytime she was out of bed and noted that it had been a while since she had seen the resident wearing it. The resident was severely cognitively impaired, requiring extensive assistance for mobility, and had complaints of acute pain related to her vertebral fractures. This discrepancy between the documented application of the neck brace and the actual observations suggests a failure in adhering to the physician's orders, potentially risking further harm to the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Saint Simons Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marsh's Edge | 3.8 mi | ★★★★★ | 0 | 0 |
| Senior Care Center - Brunswick | 5.9 mi | ★★★★★ | 0 | 0 |
| Gracemore Nursing And Rehab | 6.4 mi | ★★★★★ | 5 | 0 |
| Sears Manor Nursing Home | 6.6 mi | ★★★★★ | 0 | 0 |
| Senior Care Center - St Marys | 31.9 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.