Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Health Ctr At The Marshes Of Skidaway Island during CMS and state inspections, most recent first.
A resident requiring two-person assistance for ADLs fell and sustained fractures due to the facility's failure to follow the care plan. The care plan specified two-person assistance, but staff inconsistently adhered to this requirement, leading to the incident. Communication lapses and inadequate adherence to care protocols contributed to the deficiency.
A resident with severe cognitive impairment and requiring two-person assistance for ADL care fell while a CNA was changing bed linens alone, resulting in significant injuries. Despite the resident's care plan, the CNA declined additional help, leading to the fall. The resident, under hospice care, had a history of falls and comorbidities, including osteoporosis and heart disease.
A facility failed to follow infection control practices during wound care for a resident with a stage four pressure ulcer. The RN did not sanitize hands or change gloves during the procedure, and supplies were placed on an unclean surface. Additionally, improper laundry handling was observed, with soiled items stored improperly, risking cross-contamination. The DON acknowledged these practices were not in line with best practices.
The facility failed to ensure medications were not left at the bedside of two residents who were not assessed for self-administration. One resident with anxiety and atrial fibrillation had unauthorized medications in their room, while another with dementia and anxiety had pills and topical gel without a physician's order. The DON confirmed no residents were assessed for self-administration, and an LPN noted that bedside medications require an order.
A resident was administered celecoxib 200 mg without a specified dosage in the physician's order, contrary to the facility's medication administration policy. The nursing staff failed to transcribe the order accurately, and the consulting pharmacist's review process did not catch the error. This oversight had the potential to place the resident at risk of avoidable medical complications.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure that the care plan for a resident requiring two-person assistance for Activities of Daily Living (ADL) was followed, resulting in a fall and significant injuries. The care plan for the resident, initiated on 9/20/2024 and revised on 12/24/2024, specified the need for maximum to total assistance with ADLs, including bed mobility, transfers, locomotion, and toileting, with two persons required for assistance. On 12/16/2024, the resident fell while a Certified Nursing Assistant (CNA) was changing the bed linen, leading to bilateral femoral fractures and a right humeral fracture. Interviews revealed that there was a lack of consistent communication and adherence to the care plan. The CNA involved stated that the number of staff assisting the resident varied depending on how busy the CNAs were, and a nurse was not always available on the night shift. The Licensed Practical Nurse (LPN) was unaware of the two-person assistance requirement and had just repositioned the resident with the CNA before the incident. The Assistant Director of Nursing (ADON) indicated that care plans are communicated through walking rounds and that staff should have the cardex, which details the specific needs of each resident, on hand. However, this process was not effectively implemented, leading to the deficiency.
Resident Falls During Inadequate ADL Care
Penalty
Summary
The facility failed to protect a resident, identified as R115, from falls during Activities of Daily Living (ADL) care, resulting in significant harm. R115, who had severe cognitive impairment and was dependent on staff for self-care and mobility, required two-person assistance for ADL care. On the morning of the incident, a Certified Nursing Assistant (CNA) was changing R115's bed linen when the resident rolled out of bed and fell, resulting in bilateral femoral fractures and a right humeral fracture. The CNA was unable to prevent the fall, and the resident sustained a hematoma and a skin tear. The resident was subsequently sent to the hospital for evaluation. Interviews with staff revealed that the CNA was performing the task alone, despite the resident's care plan indicating the need for two-person assistance. The CNA reported that R115 had been more confused than usual and had attempted to get out of bed multiple times. The Licensed Practical Nurse (LPN) on duty had offered assistance, but the CNA declined, stating she could manage alone. The Director of Nursing (DON) was informed of the incident but did not come to the facility at the time. The resident was under hospice care and had a history of falls, severe cognitive impairment, and other comorbidities, including osteoporosis and atherosclerotic heart disease, which was listed as the cause of death on the death certificate.
Infection Control Deficiencies in Wound Care and Laundry Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with a stage four pressure ulcer. The Registered Nurse (RN) responsible for the wound care did not provide a clean surface for the wound care supplies, nor did she wash or sanitize her hands during the procedure. The RN applied Medihoney directly to the resident's wound bed with her finger without changing gloves or sanitizing her hands, which is against the facility's policy for standard precautions and wound care procedures. Additionally, the facility did not follow proper laundry handling procedures, which could lead to cross-contamination. During a tour of the laundry area, it was observed that soiled laundry was placed in clear trash bags and stored on top of laundry detergent containers and on the floor. The housekeeper/laundry staff admitted to placing the towels in the soiled room due to her dual responsibilities, which led to improper storage of potentially contaminated items. The Director of Nursing (DON) confirmed that the best practice would be to avoid storing clean items in the soiled laundry area, even if they are bagged, to prevent cross-contamination. The facility's failure to adhere to infection control practices during wound care and laundry handling posed a risk of infection to the residents, particularly the resident with the pressure ulcer.
Failure to Assess Residents for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside of two residents who had not been assessed for medication self-administration. Resident 7, who had diagnoses including anxiety, constipation, and atrial fibrillation, was found with stomach relief pills and diclofenac sodium gel in their room without a physician's order for self-administration. Despite having a Brief Interview of Mental Status score indicating little to no cognitive impairment, there was no documented assessment or order allowing Resident 7 to self-administer medications. Similarly, Resident 215, with a medical history including transient ischemic attack, cerebral infarction, unspecified dementia, and anxiety, was found with a bottle of pills for fever blisters and a tube of Voltaren in their room. There was no physician's order for these medications or for self-administration. The Director of Nursing confirmed the presence of these medications and stated that no residents had been assessed to self-administer medications at the time. The Licensed Practical Nurse reported that residents could keep medications at their bedside only if there was an order for self-administration.
Failure to Clarify Medication Dosage Order
Penalty
Summary
The facility failed to ensure a medication order was clarified with the physician prior to administering medication to a resident, identified as R12, during a medication pass. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication verifying the right resident, medication, dosage, time, and method of administration. However, during an observation, a registered nurse administered celecoxib 200 mg to R12 without a specified dosage in the physician's order, which was dated 9/21/2024. Interviews with the nursing staff revealed that the order for celecoxib was not transcribed accurately, as confirmed by the Assistant Director of Nursing and the Director of Nursing. The Assistant Director of Nursing stated that all nurses are responsible for transcribing physician orders, and the Director of Nursing confirmed that nursing staff are responsible for this task, with the consulting pharmacist reviewing orders when they are made and monthly. The failure to clarify the medication dosage order before administration had the potential to place R12 at risk of avoidable medical complications.
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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 Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Health & Rehab Ctr | 4.2 mi | ★★★★★ | 11 | 0 |
| Pruitthealth - Savannah | 4.9 mi | ★★★★★ | 1 | 0 |
| Azalealand Nursing Home | 5.2 mi | ★★★★★ | 6 | 0 |
| Thunderbolt Care Center Llc | 5.7 mi | — | 0 | 0 |
| Abercorn Rehabilitation Center | 6.4 mi | ★★★★★ | 11 | 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 July 2026) and official state health department websites.