Average — CMS composite of the measures below.
The next survey window likely opens around March 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 - Bethany Skilled Nursing, The during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, COPD, HTN, and generalized weakness was discharged without timely notice or adequate discharge planning. The NOMNC was not properly delivered, the resident said he was told about discharge only after breakfast and had no prior notice, and the care plan did not address community resources or other discharge needs. Staff acknowledged the notice process was delayed and that residents sometimes received less than the required notice, and the Administrator confirmed the discharge was inappropriate.
Portable oxygen tank left on floor in resident room. Staff observed a portable O2 tank sitting on the floor in the corner of a resident's room on multiple occasions. The resident had COPD and a hx of pneumonia, with a BIMS of 14, and neither the MDS nor the MD order reflected O2 therapy. The ADON, DHS, and Administrator all confirmed portable O2 tanks should be kept in holders and not on the floor.
An unlocked treatment cart was observed in a resident-accessible area with the bottom drawer open, and an LPN confirmed it was unsecured while she could not see it. A separate medication cart had dirt-like substance in drawers and a loose, unlabeled packet of Zofran; the LPN was unsure who it belonged to. The facility policy and DHS interview confirmed medication carts were to remain locked when not in use and kept clean by nursing staff.
Surveyors found that a resident room and two shower rooms were not maintained in a clean, safe, and homelike condition. One room had trash on the floor and a dark brown substance on the floor, wall, and electrical cord near the air conditioning unit over multiple days. Two shower rooms had broken and missing tiles, black substance in the corners of the walls and floors, and heavy soap scum buildup on the shower walls. The HKS, MD, CNA, and Administrator all confirmed these conditions and acknowledged that housekeeping and CNA staff were expected to perform daily cleaning and trash removal and to clean between showers.
Two residents were affected when the facility failed to follow comprehensive, person-centered care planning. One resident with COPD and acute respiratory failure had a care plan and physician order for continuous O2 at 3 L/min via nasal cannula, but surveyors repeatedly observed the concentrator set between 4.5 and 5 L/min; an LPN and the DHS confirmed the incorrect flow rate and that it had not been checked as required. Another resident with Alzheimer’s disease and a sacral fracture had an elopement assessment score indicating high elopement risk, yet no corresponding elopement problem or interventions were included in the care plan, as confirmed by the Administrator and MDS nurse.
A resident with COPD, acute respiratory failure with hypoxia, and other comorbidities had a physician order for continuous oxygen at 3 LPM via nasal cannula, supported by a care plan directing staff to administer oxygen as ordered and monitor oxygen saturations. Over multiple observations, surveyors found the resident’s oxygen concentrator set between 4.5 and 5 LPM while the resident was wearing oxygen. An LPN confirmed the concentrator setting was above the ordered rate and admitted she had not checked the oxygen flow rate or oxygen saturation that morning, despite acknowledging staff should ensure correct liter flow. The DHS also confirmed that nurses are expected to verify oxygen flow rates per orders throughout their shifts and that the resident’s oxygen had been set above the prescribed 3 LPM.
A resident with multiple chronic conditions was repeatedly found with gas relief tablets left unsecured at her bedside, despite not being care planned or assessed for self-administration of medication. Staff interviews and record reviews confirmed that medications were to be administered by staff and not left in the room, yet observations showed otherwise, resulting in a failure to ensure safe medication practices.
A resident with severe cognitive and visual impairment, and a history of falls, did not have a care-planned floor mat in place at bedside as required after a fall. Despite the care plan update, repeated observations showed the intervention was not implemented, and staff interviews revealed unclear responsibility for ensuring new interventions were put in place.
A resident with severe cognitive impairment, impaired vision, and a history of falls did not have a fall mat in place at the bedside as required by their care plan. Despite documentation that a fall mat was needed following a previous fall, multiple observations found the mat missing while the resident was in bed. The DHS confirmed the mat was not in position, attributing its absence to housekeeping staff not returning it after cleaning.
The facility failed to label and date food items, ensure dietary staff wore hair coverings appropriately, and maintain cleanliness in the kitchen, potentially affecting 89 residents. Observations revealed unlabeled cheese and ham, improper hair covering by dietary aides, and a dirty fan above the dish room, contrary to facility policies.
The facility failed to provide six residents or their representatives with written information about their right to accept or refuse medical or surgical treatment, as required by the facility's Advance Directive policy. This deficiency was identified through record reviews and staff interviews, revealing that the Admission Packet lacked necessary language to inform residents of these rights. The affected residents had various medical conditions, and there was no evidence in their records of being provided with the required information. Interviews with the Social Worker and Administrator confirmed the absence of such information and a lack of awareness of the facility's policy.
The facility failed to maintain a safe and homelike environment, with broken tiles in the E3 hall shower room, a stained privacy curtain, and a dirty motorized wheelchair for a resident on E4 hall. The laundry room had a dusty vent and an insecure entrance door, while two sinks in shared bathrooms were clogged. Staff were unclear about cleaning responsibilities, and the facility's Performance Improvement Plan did not initially address these issues.
The facility failed to maintain the dignity of two residents requiring feeding assistance. A resident with severe cognitive impairment was fed by a Unit Manager who stood due to a lack of seating, despite the care plan indicating a need for maximal assistance. Another resident was fed by a CNA who stood, contrary to training that emphasized sitting at eye level. The DON confirmed the proper procedure, but the Unit Manager was unaware of any in-services on feeding protocols.
A facility failed to assess four residents for their ability to self-administer medications, resulting in unauthorized medications being left at their bedside. Despite the facility's policy requiring a licensed nurse and physician to determine if a resident can safely self-administer medications, this procedure was not followed. Residents with varying levels of cognitive impairment were found with medications in their rooms without proper authorization or assessment, leading to a deficiency.
A facility failed to complete a timely nutrition assessment for a resident with multiple health conditions, including diabetes and chronic kidney disease. The resident was admitted without an initial nutrition assessment, despite being at risk for gastrointestinal complications. Interviews revealed that the RD was overwhelmed with responsibilities, leading to incomplete assessments. The facility's policy required assessments within 14 days, which was not met, and no policy documentation was provided.
Unsafe and Untimely Discharge Planning
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for one resident who was discharged to an environment that was not safe, placing the resident at risk for psychosocial and physical harm. The resident, R113, was admitted for rehabilitation services with diagnoses including COPD with acute exacerbation, essential hypertension, and generalized muscle weakness. The most recent MDS documented a BIMS score of 0, indicating severe cognitive impairment. The care plan did not identify or address discharge planning needs, including coordination of community resources needed to support a safe transition to the community. The facility’s discharge planning policy required a discharge summary, a Discharge Recapitulation of Stay Form, a CCD, and a copy of the face sheet, and stated that the Senior Care Partner, SSD, or administrator’s designee oversaw completion of the process. However, the NOMNC was received after the MDS Coordinator had left for the day, the resident was not informed of the last covered day, and the resident left the building before the MDS Coordinator was aware that the NOMNC had not been provided. The NOMNC was left in the resident’s room, and the resident notes indicated the resident never received a timely NOMNC prior to discharge. The NOMNC showed coverage ended before the resident’s discharge date, while services continued beyond the end of coverage and charges for several days were written off. During interviews, the resident stated he was told he was being discharged only after breakfast and was not aware of the discharge because no notice had been provided. He reported trying to speak with the DON but was refused a meeting, then contacted his brother for transportation and waited outside the facility with his belongings. The SSD stated residents had sometimes received only one to two days’ notice when five days were required and that some residents were not prepared for discharge because of late notification. The MDS Coordinator acknowledged she did not notify the resident or provide the discharge notice within the required timeframe, and the Administrator confirmed the discharge was inappropriate and that the resident should have received an appropriate discharge meeting facility and state requirements.
Portable Oxygen Tank Left on Floor in Resident Room
Penalty
Summary
A deficiency was identified for failure to ensure an area was free from accident hazards and provided adequate supervision to prevent accidents. Review of the facility policy titled Oxygen Safety and Storage stated that oxygen tanks kept in storage rooms are to be chained to the wall or installed on a stable, wheeled dolly or floor stand. In room [ROOM NUMBER] on East Hall, observations on 04/28/2026 at 4:46 PM, 04/29/2026 at 8:55 AM, and 04/29/2026 at 2:19 PM showed a portable oxygen tank sitting on the floor in the corner of the room next to the bathroom on all three occasions. Record review for R7 showed diagnoses including chronic pulmonary obstructive disease and a history of pneumonia. R7's admission MDS showed a BIMS score of 14, indicating cognitive awareness with little to no periods of confusion. R7's MDS did not reflect oxygen therapy, and the physician order also did not reflect oxygen therapy. During interview on 04/30/2026, the ADON confirmed the oxygen tank was on the floor and stated oxygen tanks should not sit on the floor. The DHS stated portable oxygen must be in a holder at all times and that holders are available on back of wheelchairs and with wheels. The Administrator also stated portable oxygen tanks in a resident's room should be kept in holders.
Unsecured and Improperly Maintained Medication Cart
Penalty
Summary
The facility failed to ensure a medication cart was locked or under direct supervision of authorized staff in an area accessible to residents for one of two wound care carts on the West Unit. On 04/29/2026 at 11:39 AM, observation showed the treatment cart on the [NAME] One unit positioned in front of room [ROOM NUMBER] West, unlocked, with the bottom drawer open. LPN DD stated she had been behind the curtain and could not see the cart, and she confirmed the cart was unlocked and the bottom drawer was open. On 04/29/2026 at 2:39 PM, observation of the East Two-unit medication cart with LPN CC showed the third and fourth drawers contained a dirt-like substance in the back of the cart. One packet of Zofran was observed loose in the middle drawer and did not have a label with a resident's name, and LPN CC stated she was unsure whom the Zofran belonged to. The facility policy stated medications and biologicals are to be stored safely and securely, and interviews with the Pharmacy Consultant and the DHS confirmed that medication carts were to remain locked when not in use and that nurses were responsible for keeping medication carts clean and free of expired medications.
Failure to Maintain Clean and Sanitary Resident Room and Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in a resident room and two shower rooms, contrary to its housekeeping and infection control policy. Surveyors observed that one resident room on the West unit had trash on the floor between the air conditioning unit and the bed on multiple days, along with a dark brown substance on the floor, electrical cord, and wall above the air conditioning unit. These conditions persisted over repeated observations. The Housekeeping Supervisor confirmed the presence of trash and the dark brown substance and stated that housekeeping staff were expected to clean high-touch areas and remove trash daily. A CNA reported that she did not pick up the trash in that room and stated that trash should be checked and removed when providing care. The Administrator also confirmed observing trash, cups, and the dark brown substance on the floor, wall, and electrical cord and stated that trash removal was everyone’s responsibility. The deficiency also includes unsanitary and poorly maintained conditions in two shower rooms. Observations of the East 2 shower room and the Garden Wing shower room revealed broken and missing tiles, a dark or black substance in the corners of the walls and floors, and a buildup of white soap scum on the shower walls. These conditions were noted on more than one day and were confirmed by the Maintenance Director, Housekeeping Supervisor, and Administrator during joint observations. The Housekeeping Supervisor acknowledged that the showers needed to be cleaned and stated that housekeeping staff were responsible for daily cleaning and that CNA staff should clean between patients, while also noting that this was her first time seeing the shower rooms.
Failure to Implement Oxygen Orders and Care Plan for Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered comprehensive care plans for two residents in accordance with physician orders and assessed risks. For one resident with COPD, acute respiratory failure with hypoxia, anxiety disorder, type 2 diabetes mellitus, heart failure, and other conditions, the care plan dated 10/13/2025 identified altered respiratory status and directed staff to administer oxygen via nasal cannula as ordered by the physician and to monitor oxygen saturations. The physician order dated 1/29/2026 specified oxygen at 3 liters per minute via nasal cannula, continuous. However, on multiple observations over several days, the resident was noted to be receiving oxygen at between 4.5 and 5 liters per minute. An LPN confirmed the concentrator was set between 4.5 and 5 liters per minute, acknowledged that the order was for 3 liters per minute continuous, and stated she had not checked the flow rate or oxygen saturation that morning. The Director of Health Services also confirmed the incorrect flow rate and stated that nurses should ensure the correct liter flow is set and check oxygen flow rates throughout their shifts. The MDS Coordinator confirmed the care plan was for oxygen as ordered and that staff should follow the care plan and physician orders. The second deficiency concerns the facility’s failure to care plan for an assessed elopement risk for another resident. This resident was admitted with diagnoses including a non-displaced fracture of zone 1 sacrum and Alzheimer’s disease. The admission MDS showed that a BIMS assessment was not performed because the resident was rarely or never understood. An Elopement Assessment dated 1/17/2026 documented a score of 17, indicating a high risk for elopement. Despite this assessment, review of the resident’s care plan revised 2/4/2026 revealed no documented care plan problem addressing elopement risk. The Administrator stated that all residents were assessed for elopement risk as part of an elopement prevention improvement plan and confirmed that all residents identified as at risk for elopement should have a care plan problem for elopement. The MDS Nurse likewise confirmed that all residents identified as a risk for elopement should have a care plan for elopement.
Failure to Follow Physician-Ordered Oxygen Flow Rate
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care related to failure to regulate and monitor oxygen liter flow rates according to physician orders for one resident. Facility policy titled "Oxygen Administration" revised 8/2/2023 states that oxygen is to be provided safely and accurately and that staff are to regulate liter flow to the ordered/desired flow rate. The resident involved had a recent Quarterly MDS dated 1/20/2026 showing a BIMS score of 15, indicating little to no cognitive impairment, and active diagnoses including COPD, acute respiratory failure with hypoxia, anxiety disorder, type 2 diabetes mellitus, heart failure, and functional dyspepsia. The resident’s care plan, dated 10/13/2025, documented altered respiratory status/difficulty breathing related to COPD, with interventions including administering oxygen via nasal cannula as ordered by the physician and monitoring oxygen saturations as ordered. Physician orders for this resident, dated 1/29/2026, specified oxygen at 3 LPM via nasal cannula, continuous. However, multiple observations showed the oxygen concentrator set above the ordered rate: on 2/3/2026 at 12:55 PM the flow rate was between 4.5 and 5 LPM; on 2/4/2026 at 12:10 PM it was set at 5 LPM; and on 2/5/2026 at 9:50 AM it was again between 4.5 and 5 LPM while the resident was wearing oxygen. During an observation and interview on 2/5/2026 at 10:10 AM, an LPN confirmed the concentrator was set between 4.5 and 5 LPM and stated that staff should ensure residents receive the correct oxygen liters per minute, acknowledging that this resident’s flow rate should have been 3 LPM continuous. The LPN reported she had not checked the oxygen flow rate or oxygen saturation that morning and should have done so. The Director of Health Services later confirmed that nurses are expected to ensure the correct liter flow per physician orders and to check oxygen flow rates throughout their shifts, and confirmed that the resident’s oxygen flow rate had been between 4.5 and 5 LPM.
Failure to Assess and Secure Self-Administered Medication
Penalty
Summary
A resident with multiple diagnoses, including GERD, dysphagia, chronic kidney disease, diabetes, hypertension, and atrial fibrillation, was observed on several occasions with two thick white tablets on her overbed table. The resident stated these were gas relief tablets provided by the nurses, which she took after meals. Review of the clinical record confirmed a physician's order for chewable gas relief tablets to be administered as needed. However, the care plan did not indicate that the resident was to self-administer medication or keep medications at bedside, and a prior assessment documented that the resident did not wish to self-administer medications, with staff responsible for administration. Despite this, observations confirmed that the medication was left unsecured in the resident's room on multiple dates. Interviews with an LPN and the Director of Health Services confirmed that the medication should not have been left in the room and that staff were responsible for administering it. The LPN stated she only gave the medication when requested and did not leave it in the room, yet the medication was repeatedly found at the bedside, indicating a failure to follow established protocols for medication administration and security.
Failure to Implement Care Plan Intervention for Fall Prevention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident who was at risk for falls. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder, was assessed as having highly impaired vision, severe cognitive impairment, and required assistance with activities of daily living. Following a fall incident in which the resident was found on the floor with an abrasion to the forehead, the care plan was updated to include a floor mat at the bedside as a preventive intervention. Despite this update, multiple observations over several days showed that the floor mat was not present at the resident's bedside as specified in the care plan. Staff interviews indicated uncertainty about responsibility for implementing new interventions after a fall, with the administrator stating it could be any staff member but ultimately the unit manager's responsibility. This failure to implement the care plan intervention as documented placed the resident at risk for safety and injury.
Failure to Ensure Fall Mat in Place for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a fall mat, identified as a necessary intervention, was in place for a resident with significant risk factors. The resident had diagnoses including dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder. Clinical assessments documented highly impaired vision, severe cognitive impairment, and a need for assistance with activities of daily living. After a fall incident in which the resident was found on the floor with an abrasion to the forehead, the interdisciplinary team determined that a fall mat should be placed at the bedside to reduce the risk of injury from future falls. Despite this intervention being documented in the care plan, multiple observations over several days showed that the fall mat was not present at the resident's bedside while the resident was in bed. During an interview, the Director of Health Services acknowledged that the fall mat was in the room but had been moved behind a chair, possibly by housekeeping staff after cleaning, and was not returned to its proper place. This lapse in ensuring the fall mat was in position constituted a failure to provide adequate supervision and accident hazard prevention as required.
Deficiencies in Food Labeling, Staff Hygiene, and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to its policies regarding food labeling, staff hygiene, and cleanliness in the kitchen, which could potentially affect 89 out of 96 residents receiving an oral diet. During a kitchen tour, it was observed that a package of cheese and a bag of diced ham were not labeled or dated, contrary to the facility's policy that requires all food and beverage items to have an identifying label, received date, and opened date. This oversight was confirmed by a staff member, who acknowledged that without proper labeling, there would be no way to determine when to discard the items, potentially leading to foodborne illness. Additionally, the facility did not ensure that dietary staff wore hair coverings appropriately, as observed with two dietary aides who did not have their hair completely covered. This was against the facility's hygiene policy, which mandates that hair be covered with a hair net or cap. Furthermore, a fan mounted above the dish room was found to be covered in dirt, dust, and grime, which could contaminate food or dishes. The Dietary Manager confirmed these findings and acknowledged the importance of maintaining cleanliness and proper hygiene practices in the kitchen.
Failure to Provide Residents with Information on Treatment Rights
Penalty
Summary
The facility failed to provide six residents or their representatives with written information regarding their right to accept or refuse medical or surgical treatment, as required by the facility's Advance Directive policy. This deficiency was identified through record reviews, staff interviews, and examination of the facility's policy. The facility's Admission Packet did not contain the necessary language to inform residents or their representatives about these rights, which is a critical component of the admission process. The deficiency affected residents with various medical conditions, including anoxic brain damage, chronic respiratory failure, hemiplegia, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, chronic kidney disease, diabetes mellitus, heart failure, and malignant neoplasm of the prostate. Despite the presence of these conditions, there was no evidence in the medical records of these residents that they or their representatives were provided with the required written information about their rights to accept or refuse treatment. This lack of documentation was confirmed through interviews with the Social Worker and the Administrator, who acknowledged the absence of such information in the admission packets. The Social Worker and Administrator interviews revealed a lack of awareness and understanding of the facility's Advance Directive checklist and the residents' rights to accept or refuse treatment. The Administrator admitted to being unfamiliar with the checklist and indicated that it was being revised by corporate. This oversight resulted in all residents in the facility not receiving the necessary materials on their rights, highlighting a systemic issue in the facility's admission process and policy implementation.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe and homelike environment in several areas, including the E3 and E4 halls, the [NAME] wing, and the laundry room. On the E3 hall, the shower room had broken wall tiles with sharp edges, posing a hazard to residents. The facility's Performance Improvement Plan (PIP) did not identify the need for tile replacement, and the issue was only acknowledged after being pointed out by a surveyor. Additionally, the laundry room had a ceiling vent coated with a dark greyish substance, and the entrance door could not close securely due to a large space, potentially allowing contaminants to enter. Resident R19, who has a primary diagnosis of malignant neoplasm of the lung and mild-moderate cognitive impairment, was found to have a stained privacy curtain and a motorized wheelchair with a build-up of brownish-black debris. The care plan for R19 did not initially address the cleaning of the motorized wheelchair, and there was confusion among staff regarding responsibility for cleaning wheelchairs. Interviews with housekeeping aides and nursing staff revealed inconsistencies in the cleaning schedule and procedures for wheelchairs, with the housekeeping supervisor confirming that motorized wheelchairs were only sanitized and not thoroughly cleaned. Furthermore, two sinks in shared bathrooms on the [NAME] wing were clogged and holding water, which was confirmed during an observation and interview with the Administrator. The facility's failure to address these maintenance and cleanliness issues contributed to an environment that did not meet the standards for safety and homeliness, as required for resident care.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to promote and maintain the dignity of two residents who required assistance with feeding. Resident 11, diagnosed with Parkinson's disease, moderate protein-calorie malnutrition, and other conditions, was observed being fed by the Unit Manager while standing beside the bed on two separate occasions. The resident's care plan indicated a need for substantial maximal assistance with feeding due to severe cognitive impairment. Despite this, the Unit Manager admitted to standing while feeding the resident because there was no extra chair in the room and was unsure of the proper procedure for feeding residents. Similarly, Resident 67, who had severe cognitive impairment and was dependent on assistance for eating, was observed being fed by a CNA who was also standing. The CNA acknowledged that training had been provided on the proper feeding procedure, which includes sitting at eye level with the resident. The Director of Nursing confirmed that staff should sit at eye level and elevate the head of the bed when feeding residents. However, the Unit Manager was unaware of any in-services on feeding procedures, and the Administrator noted that while sitting with the resident is not required, it is considered best practice.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess four residents for their ability to self-administer medications before leaving medications at their bedside. This oversight was identified during observations, interviews, and record reviews, revealing that medications were accessible to residents without proper authorization or assessment. The facility's policy requires a licensed nurse and physician to determine if a resident can safely self-administer medications, but this procedure was not followed for the residents in question. Resident 55, who has mild cognitive impairment and several medical conditions, was found with over-the-counter eye drops and pain relief cream at her bedside, which her daughter had brought from home. There was no physician's order for these medications, nor was there an assessment or care plan for self-administration. Similarly, Resident 37, with moderate cognitive impairment, had unauthorized medications, including acetaminophen and medicated chest rub, visible in her room. Resident 75, with severe cognitive impairment, had lidocaine pain medication at his bedside, which he used without staff supervision. Resident 82, despite having no cognitive impairment, also had unauthorized medications, including inhalation powder, in her room. The Licensed Practical Nurse (LPN) confirmed the presence of unauthorized medications in the residents' rooms and acknowledged that the residents had not been assessed or approved for self-administration. The facility's protocol requires an evaluation and care plan for any resident approved to self-administer medications, but this was not adhered to, leading to the deficiency. The administrator confirmed that residents should not have medications in their rooms without proper assessment and approval.
Failure to Complete Timely Nutrition Assessment for Resident
Penalty
Summary
The facility failed to provide evidence that a nutrition assessment was completed by a Registered Dietitian (RD) for a resident, identified as R88, upon admission. R88 was admitted with multiple diagnoses, including gastro-esophageal reflux disease, chronic obstructive pulmonary disease, chronic kidney disease, and type 2 diabetes mellitus with diabetic nephropathy. Despite these conditions, which necessitate careful nutritional management, there was no admission nutrition assessment documented. The resident's care plan noted a risk for gastrointestinal complications and altered nutrition, highlighting the importance of a timely nutritional assessment. Interviews with facility staff revealed systemic issues contributing to the deficiency. The prior RD, who left the facility in December 2024, indicated that managing nine buildings was overwhelming, leading to incomplete assessments. The RD acknowledged that some admission assessments were not completed and that she attempted to catch up on overdue assessments. The Regional Nurse Consultant and the Administrator both confirmed that the facility's policy required nutritional assessments within 14 days of admission, which was not met for R88. The facility was unable to provide a policy on nutrition assessments when requested, further indicating a lapse in adherence to established protocols.
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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 Vidalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oxley Park Health And Rehabilitation | 2.2 mi | ★★★★★ | 11 | 0 |
| Meadows Park Health And Rehabilitation | 3.3 mi | ★★★★★ | 0 | 0 |
| Treutlen County Health And Rehabilitation | 16.9 mi | ★★★★★ | 3 | 0 |
| Glenwood Health And Rehabilitation | 17.5 mi | ★★★★★ | 22 | 0 |
| Tattnall Healthcare Center | 18 mi | ★★★★★ | 10 | 0 |
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