Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oaks - Athens Skilled Nursing, The during CMS and state inspections, most recent first.
Dietary staff failed to properly label and date pre-portioned salad dressings and nutrition supplements stored in multiple kitchenette refrigerators. Surveyors found steam table pans with no identifying labels or dates, and the DM confirmed the items were not properly labeled or dated; the DM also stated aides were responsible for dating the pans and that thawed supplements were to be used within 14 days.
Dietary staff did not follow the facility’s equipment cleaning policy requiring freezer elements to be kept free of frost and ice build-up. Surveyors observed two separate kitchenette countertop freezers, each with three shelves, where the middle shelf was completely covered with thick frost and ice cream cups were stored within or on the frost. During interviews, the DM confirmed the frost build-up and the storage of ice cream cups in the frost, and reported that these freezers were only cleaned and defrosted when visible frost appeared, with no established defrosting schedule.
Failure to Assess Resident for Self-Administration of Medication: A resident with dementia, delirium, cognitive communication deficit, and a BIMS score of 0 had a bottle of Magic Mouthwash left accessible at bedside without documentation of assessment or authorization for self-administration. The EMR, physician orders, and care plan did not support resident self-administration, while staff confirmed the medication should not have been kept in the room and that residents were not allowed to self-administer unless assessed and authorized.
Medication carts were left unlocked and unattended on two halls. An LPN left a cart in the hallway while entering a resident room, and another LPN kept a cart unlocked while cleaning at the nurse station, stating it did not need to be locked as long as she was nearby. The DON and Administrator stated carts must be secured unless directly attended by licensed nursing staff.
The facility failed to maintain effective infection control, as observed in two incidents. The Maintenance Director did not change his N-95 mask after exiting a TBP room, contrary to policy. An LPN did not use PPE or perform proper hand hygiene during catheter care for a resident on EBP, and failed to clean the catheter tubing tip. These actions risked spreading infection in the facility.
The facility failed to ensure safe handling and storage of oxygen canisters and proper use of a mechanical lift. A CNA improperly handled oxygen tanks, and there was confusion about storage procedures. Additionally, a resident fell from a mechanical lift due to improper use and lack of training, highlighting deficiencies in supervision and adherence to procedures.
A facility failed to provide adequate nursing staff, resulting in delayed care for residents. One resident, post-surgery, was left in feces for 30 minutes, raising infection concerns. Another resident experienced a three-hour delay for assistance, and a third was denied bathroom access during mealtime, leading to incontinence. Staff interviews and resident council meetings confirmed ongoing issues with untimely call light responses and insufficient staffing.
A facility failed to report a significant medication error and allegations of sexual abuse within the required timeframe. A resident was given the wrong medications, resulting in harm and ICU admission. Additionally, two residents were involved in a sexual incident that was not reported promptly. These failures indicate noncompliance with reporting requirements, posing serious risks to resident safety.
A resident with a history of serious health conditions experienced harm due to a medication error at an LTC facility. The resident was given incorrect medications, leading to bradycardia and hypotension, and was admitted to the ICU. The facility failed to follow the resident's care plan, which included specific medication instructions, and did not report the error promptly, contributing to the immediate jeopardy situation.
A resident experienced harm after a registered nurse allegedly administered medications not prescribed for her, including allopurinol, amlodipine, and others, leading to bradycardia and hypotension. The resident, with a history of cerebral infarction and other conditions, was transferred to the ICU for treatment. The facility failed to follow its medication administration policy, contributing to the incident.
A resident experienced harm due to a significant medication error when a nurse administered incorrect medications, leading to hospitalization. The facility administration failed to report this incident and an allegation of sexual abuse between two residents in a timely manner, highlighting deficiencies in oversight and compliance with reporting regulations.
Improper Labeling and Dating of Prepared Foods and Supplements
Penalty
Summary
Dietary staff failed to ensure prepared food items were properly labeled and dated in accordance with the facility policy titled, "Labeling, Dating, and Storage." The policy required food and beverage items to have an identifying label and received/opened date as applicable, and items prepared onsite to also have a use-by date. During observations of multiple hall kitchenettes, surveyors found refrigerated pull-out drawers containing steam table pans with pre-portioned salad dressings and nutrition supplements, and none of the individual salad dressing containers or the pans had labels or dates. Surveyors observed this condition in the 600 hall kitchenette, the 500, 700, and 800 hall kitchenette, and the 100, 200, 300, and 400 hall kitchenette. The pans containing four-ounce cartons of nutrition supplements had no date showing when the supplements were defrosted and placed in the pans, and the Dietary Manager confirmed the items were not properly labeled or dated. The DM stated dietary aides portioned the salad dressings in the main kitchen and were responsible for dating the pans before bringing them to the kitchenettes, and that dietary staff were expected to date the pans when the nutrition supplements were removed from the freezer and placed in the pans. The DM also stated the supplements were to be used within 14 days after thawing.
Improper Frost Build-Up Management in Kitchenette Freezers
Penalty
Summary
Dietary staff failed to maintain kitchenette freezers free of frost build-up as required by the facility’s policy titled “Cleaning Procedures: Major Equipment,” which states that walk-in freezers must be kept free of frost and ice build-up on a daily basis. During observation of the kitchenette serving the 500, 700, and 800 halls, surveyors noted a small countertop freezer with three shelves in which the middle shelf was fully covered with approximately one inch of frost, and ice cream cups were stored within the frost. In a separate kitchenette serving the 100, 200, 300, and 400 halls, another small countertop freezer with three shelves was observed, with the middle shelf fully covered with a thick layer of frost and ice cream cups stored on the frost. In interviews conducted at the time of each observation, the Dietary Manager confirmed the presence of frost build-up and the storage of ice cream cups within or on the frost in both freezers, and stated that these freezers were cleaned and defrosted only when visible frost was noticed, with no set schedule for defrosting. No specific residents or their medical conditions were mentioned in the report, and the deficiency centers on the condition and maintenance of the dietary equipment rather than on individual resident care events.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess one of 46 sampled residents, R13, for self-administration of medication. Review of the facility policy stated that residents may self-administer medications only if they have the cognitive and functional capacity to do so and only with a specific written order from a physician or other authorized provider, obtained on a semi-annual basis. However, the electronic medical record contained no documentation that R13 had been assessed or authorized to self-administer medications, and physician orders did not list Magic Mouthwash as a self-administration medication or authorize bedside storage. On observation, a bottle of Magic Mouthwash was found sitting on R13’s windowsill and accessible at bedside rather than secured. R13’s record showed diagnoses including unspecified dementia with anxiety, delirium, cognitive communication deficit, dysphagia, restlessness and agitation, depression, fracture of the left wrist, sacral fracture, and generalized muscle weakness. The quarterly MDS documented a BIMS score of 0, substantial to maximal assistance with multiple ADLs, and use of antipsychotic, antidepressant, antibiotic, opioid, and antiplatelet medications. The care plan described impaired cognition, inability to make daily decisions without cues and supervision, and need for supervision, but it did not include interventions supporting self-administration of medications.
Medication carts left unlocked and unattended
Penalty
Summary
The facility failed to properly lock and secure two of six medication carts, including the 600 hall medication cart and the 800 hall medication cart. The facility policy titled Medication Storages in Healthcare Centers stated that medications and biologicals are to be stored securely and that medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. On 02/17/2026 at 11:10 AM, an LPN entered a resident room on the 800 hall while the medication cart was left unattended in the hallway and observed unlocked with no licensed staff present. When questioned, the LPN stated he realized he had left the cart unattended and acknowledged he was not supposed to leave it unlocked. On 02/22/2026 at 06:37 AM, an LPN on the 600 hall was observed cleaning and wiping down the nurse station while the medication cart remained unlocked and unattended; the LPN stated that as long as she was in the area, the cart did not have to be locked unless she was going into a resident's room. The DON and Administrator both stated that medication carts should not be left open unless directly attended by licensed nursing staff.
Infection Control Deficiencies in PPE and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. One incident involved the Maintenance Director (MD) who exited a Transmission Based Precautions (TBP) room without properly changing his N-95 mask, which is against the facility's policy. The MD admitted to being aware of the requirement but neglected to follow it due to being in a hurry. The Infection Preventionist (IP) confirmed that the MD was not present during the initial in-service training on PPE protocols, although subsequent training was provided. Another deficiency was observed with a Licensed Practical Nurse (LPN) who failed to adhere to Enhanced Barrier Precautions (EBP) while performing catheter care on a resident. The LPN did not don personal protective equipment (PPE) upon entering the resident's room, which was required due to the resident's condition and EBP status. Additionally, the LPN did not perform hand hygiene between glove changes and failed to clean the catheter tubing tip after emptying the drainage bag, as per the facility's catheter care procedure. The resident involved in the catheter care deficiency had a medical history that included sepsis due to Escherichia Coli, a urinary tract infection, and a stage 4 pressure ulcer. The Director of Health Services (DHS) and the IP both confirmed that PPE should have been used during high-contact care activities, such as catheter care, and that hand hygiene should be performed before and after glove use, as well as between glove changes. These lapses in protocol had the potential to spread infection throughout the facility, which had a census of 112 residents at the time of the survey.
Deficiencies in Oxygen Handling and Mechanical Lift Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards related to the handling and storage of oxygen canisters. Observations revealed that a Certified Nursing Assistant (CNA) improperly handled oxygen tanks by dragging them across the floor and leaving a half-empty tank outside the storage closet. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), indicated a lack of clarity and adherence to the facility's policy on oxygen safety and storage. The CNA was not authorized to handle the tanks, and there was confusion about where to store partially used tanks, which could lead to potential safety hazards. Additionally, the facility failed to use a mechanical lift device according to its procedure and manufacturer recommendations when transferring a resident. The resident, who was dependent on staff for all activities of daily living and required a two-person mechanical lift, experienced a fall when the lift tipped over. The incident occurred because the CNA operating the lift had not been properly trained, and the second CNA did not assist with the lift operation as required. The resident was not injured, but the incident highlighted a failure to follow the established procedure for using mechanical lifts. The resident involved in the mechanical lift incident had a history of respiratory distress, cerebral vascular accident, and other medical conditions, making her dependent on staff for care. The incident report and interviews with staff confirmed that the fall was due to improper use of the lift, including not spreading the legs for balance and not locking the shower chair wheels. The lack of proper training and adherence to procedures contributed to the deficiency in providing adequate supervision and safe handling of equipment.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed care for three residents. Resident R251, who had undergone recent orthopedic surgery and was at risk for complications due to incontinence and decreased mobility, experienced a significant delay in receiving assistance after a laxative was administered. Despite calling for help, she was left sitting in feces for approximately 30 minutes before staff arrived to assist her. The family expressed concerns about the inadequate cleaning of her surgical wounds, leading to her being transported to a hospital for further examination. Resident R114, who required catheter and ostomy care, reported excessive wait times for assistance, including a three-hour delay in response to a call light. Observations confirmed that R114 was consistently the last to be served meals, indicating a pattern of delayed care. The resident expressed dissatisfaction with the facility's staffing levels, noting that call lights were not answered promptly and that administrative nurses did not assist with resident care. Resident R718, with moderate cognitive impairment and incontinence issues, also experienced delays in receiving care. During mealtime, the resident was denied assistance to use the bathroom, resulting in an incontinent episode. The resident council meetings and grievance logs further highlighted ongoing issues with untimely call light responses and inadequate staffing. Interviews with staff, including CNAs and LPNs, corroborated these concerns, with staff expressing frustration over being short-staffed and unable to meet residents' needs effectively.
Failure to Report Medication Error and Abuse Allegations
Penalty
Summary
The facility failed to report a significant medication error involving a resident who was administered the wrong medications, resulting in actual harm. The resident, who had a history of cerebral infarction, aortic valve stenosis, hypertension, and hypercholesteremia, was given approximately 14 pills, including medications not prescribed to her. This error led to a change in her condition, causing bradycardia and hypotension, and necessitated her transfer to the Intensive Care Unit for higher-level care. The incident was not reported to the state agency in a timely manner, as required by the facility's policy. Additionally, the facility did not report allegations of sexual abuse within the required timeframe. Two residents were involved in an incident where one resident was found in another's room, receiving oral gratification. The facility's policy mandates that such incidents be reported to the appropriate state agency within two hours if they involve abuse or result in serious bodily injury. However, the incident was not reported until ten days later, indicating a failure to adhere to the reporting requirements. The facility's noncompliance with reporting requirements was identified as causing or having the likelihood to cause serious injury, harm, impairment, or death to residents. The failure to report these incidents promptly and appropriately highlights significant deficiencies in the facility's adherence to federal and state regulations regarding the reporting of patient abuse, neglect, and significant medication errors.
Medication Error and Care Plan Noncompliance
Penalty
Summary
The facility failed to follow a comprehensive person-centered care plan for a resident with a history of cerebral infarction, malignant neoplasm, aortic valve stenosis, hypertension, and hypercholesteremia. The care plan included specific instructions to avoid administering nitroglycerin due to severe aortic stenosis and to monitor for symptoms such as chest pain, syncope, dizziness, palpitations, or weakness. Despite these instructions, a significant medication error occurred when the resident was allegedly given the wrong medications, leading to a change in condition characterized by bradycardia and hypotension. On the day of the incident, the resident was preparing for discharge when they reported feeling unwell and having been given approximately 14 pills, including two large blue pills not typically part of their regimen. The resident's family was present and aware of the situation. The resident was subsequently sent to the emergency room and admitted to the Intensive Care Unit with a diagnosis of poisoning by beta-adrenergic receptor antagonist, which was accidental and unintentional. The resident required intravenous glucagon, fluids, and calcium to manage the adverse effects. The facility's failure to report the significant medication error promptly contributed to the immediate jeopardy situation. The error was not reported until a later date, and the facility's noncompliance with reporting requirements was identified as a contributing factor to the harm experienced by the resident. The incident highlighted deficiencies in medication administration practices and the need for adherence to established care plans to prevent similar occurrences.
Significant Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in actual harm. On the morning of 9/14/2024, a registered nurse allegedly administered medications to a resident that were not prescribed for her. These medications included allopurinol, amlodipine, Eliquis, ferrous sulfate, Lasix, losartan, metoprolol, oxcarbazepine, potassium chloride, valsartan, and vitamin D3. The resident experienced a change in condition, specifically bradycardia and hypotension, and was subsequently transferred to the hospital's Intensive Care Unit for treatment. The resident involved had a medical history that included cerebral infarction due to embolism, malignant neoplasm of the bronchus or lung, aortic valve stenosis, hypertension, and hypercholesteremia. At the time of the incident, the resident was reported to have a Brief Interview for Mental Status score of 15, indicating no cognitive impairment, and required partial assistance with some activities of daily living. The medication error was discovered when the resident reported dizziness and headache, leading to her being sent to the emergency room. The facility's policy on medication administration was not followed, as medications were allegedly administered that were not prescribed for the resident. The error was not immediately reported, and the facility's failure to adhere to its own medication administration guidelines contributed to the incident. The registered nurse involved denied administering the wrong medications, but the resident and her family reported otherwise, leading to further investigation and confirmation of the error.
Medication Error and Reporting Failures
Penalty
Summary
The facility administration failed to ensure that a resident was free from significant medication errors, which resulted in actual harm. On 9/14/2024, a registered nurse administered incorrect medications to a resident, including allopurinol, amlodipine, Eliquis, ferrous sulfate, Lasix, losartan, metoprolol, oxcarbazepine, potassium chloride, valsartan, and vitamin D3. This error led to a change in the resident's condition, causing bradycardia and hypotension, necessitating a transfer to the hospital and admission to the Intensive Care Unit (ICU) with a diagnosis of poisoning by beta-adrenergic receptor antagonist - accidental. The administration also failed to report the significant medication error incident in a timely manner, as required by regulations. The incident occurred during the 9:00 a.m. medication pass, but it was not reported within the mandated two-hour timeframe. This delay in reporting was acknowledged by the facility's administrator, who initially did not consider the medication error as an adverse incident that needed to be reported to the State Survey Agency (SSA). Additionally, the facility administration failed to report an allegation of sexual abuse between two residents in a timely manner. The incident occurred on 7/6/2024, but it was not reported until 7/16/2024. The Senior Nurse Consultant confirmed that the facility should have reported the incident on the day it occurred. These failures in reporting and addressing significant incidents highlight deficiencies in the facility's administration and oversight processes.
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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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Nursing homes near Athens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Grandview | 0.9 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Athens Heritage | 1.4 mi | ★★★★★ | 6 | 0 |
| Presbyterian Village - Athens | 2.9 mi | ★★★★★ | 1 | 0 |
| University Nursing & Rehab Ctr | 3.4 mi | ★★★★★ | 0 | 0 |
| High Shoals Health And Rehabilitation | 11.2 mi | ★★★★★ | 0 | 0 |
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