Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Sardis Oaks during CMS and state inspections, most recent first.
A resident with a history of stroke and dysphagia, who was receiving nutritional supplements via PEG tube, was not accurately coded on the quarterly MDS assessment. The assessment failed to indicate the use of a feeding tube and did not include required details about calories and fluid intake from tube feeding, despite clear documentation and staff awareness of the resident's nutritional regimen.
A resident who was initially admitted with physical health conditions later received new diagnoses of major depressive disorder and paranoid personality disorder. Despite these new serious mental illness diagnoses, staff did not submit a required Level II PASRR evaluation request due to an oversight, as confirmed by the SW, DON, and administrator.
A nurse failed to properly clean and store a tube feeding syringe after administering medication to a resident with a gastric tube and severe cognitive deficit. The syringe was rinsed, reassembled while still wet, and stored in a plastic bag with visible water, contrary to facility procedures requiring air drying and separate storage of parts. The DON confirmed that stagnant water could promote bacterial growth.
A nurse prepared an IV antibiotic for a resident by connecting a Cefepime vial to a normal saline bag without cleaning the medication port with an alcohol swab, contrary to facility procedure. The nurse believed the port did not require cleaning, but both the DON and Administrator confirmed that cleaning with alcohol is required to prevent contamination.
The facility failed to post cautionary signage indicating oxygen use in resident rooms for four residents receiving respiratory care. Despite being a non-smoking campus, the absence of specific oxygen use signs at resident doors was noted as a deficiency. Residents receiving continuous or as-needed oxygen therapy did not have appropriate safety signage, as the facility relied on general tobacco-free campus signage at the main entrance.
The facility failed to maintain proper hand hygiene, food storage, and staff attire protocols. A dietary aide did not perform hand hygiene while handling food, and several food items were improperly stored without labels or dates. Additionally, staff were observed without proper hair and beard restraints. These issues were not identified during routine checks by the kitchen supervisor and dietary manager.
A resident with dysphagia and a gastrostomy tube was receiving continuous tube feeding, but the facility failed to label the feeding formula with the date and time it was hung. The responsible nurse admitted to forgetting to label the bottle, and the DON confirmed that labeling is required by facility protocol.
A nurse aide failed to wear a gown while providing care to a resident under Enhanced Barrier Precautions (EBP) for a feeding tube, despite the facility's policy requiring both gown and gloves for high-contact activities. The aide admitted to forgetting the procedure due to a busy morning, although she was aware of the EBP requirements. Interviews with the Infection Preventionist and DON confirmed the necessity of wearing both gown and gloves in such situations.
A resident's air conditioner was nonfunctional for three weeks, leading to discomfort due to high temperatures. Despite reporting the issue, the maintenance director was only informed days before the surveyor's visit and did not take immediate action to provide temporary relief. The facility failed to maintain a comfortable environment, as expected by the administrator.
A resident with hemiplegia and blindness, requiring assistance with ADLs, was found with long, dirty fingernails due to inadequate nail care by staff. Despite the resident's requests, staff failed to trim her nails, assuming she did not want them trimmed. The DON and Administrator were unaware of the issue, highlighting a communication lapse in the facility.
A resident with severe cognitive impairment and type 2 diabetes was found with an exposed insulin syringe on their bedside table. The nurse responsible for administering the insulin forgot to dispose of the syringe in a sharps container, as required by facility protocol. Interviews with the DON and Administrator confirmed the oversight.
Inaccurate MDS Coding for Resident Receiving Tube Feeding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident with a history of stroke and dysphagia who had a percutaneous endoscopic gastrostomy (PEG) tube for nutritional support. Despite physician orders and documentation indicating the resident was receiving specialized nutritional supplements via PEG tube, the quarterly MDS assessment did not reflect the use of a feeding tube, nor did it include the proportion of total calories and average fluid intake received through tube feeding. Interviews with facility staff revealed that the Registered Dietician (RD), who was responsible for coding the Swallowing/Nutritional Status section of the MDS, did not complete this section accurately. The RD acknowledged missing the required coding for the feeding tube and related nutritional information. The MDS Coordinator and Director of Nursing confirmed that the MDS should have been completed accurately, and the Administrator also stated that the MDS should be coded correctly.
Failure to Submit Level II PASRR Evaluation for Resident with New Serious Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who received a new diagnosis of a serious mental illness after admission. The resident was initially admitted with diagnoses of lymphedema, cellulitis, and an open wound, and a Level I PASRR was completed prior to admission. Subsequent medical record review showed that the resident was later diagnosed with major depressive disorder and paranoid personality disorder, and was receiving antidepressant and anticonvulsant medications. Despite these new diagnoses, there was no evidence in the electronic medical record that a Level II PASRR evaluation request was submitted. Interviews with facility staff revealed that the process for submitting a Level II PASRR evaluation involved nursing notifying the social worker (SW) when a resident received a new diagnosis of a serious mental illness. The SW was then responsible for submitting the request. Both the SW and the Director of Nursing (DON) acknowledged that the request for a Level II PASRR evaluation was not submitted for this resident due to an oversight. The administrator confirmed that a request should have been made when a new qualifying mental health diagnosis was identified.
Improper Cleaning and Storage of Tube Feeding Syringe
Penalty
Summary
Nurse #1 failed to properly clean and store a tube feeding syringe after administering medication to Resident #79, who had a gastric tube and severe cognitive deficit. The nurse rinsed the syringe parts with tap water, reassembled the syringe without allowing it to air dry, and placed it in a plastic bag with visible water remaining inside both the syringe and the bag. This practice was observed during medication administration and was acknowledged by the nurse as routine. The facility's procedure, as described by the DON, required disassembling the syringe, rinsing with warm water, air drying on a paper towel, and storing the parts separately in a plastic bag, which was not followed in this instance. The DON confirmed that stagnant water could promote bacterial growth.
Failure to Clean IV Medication Port Prior to Mixing Antibiotic
Penalty
Summary
Nurse #1 was observed preparing an intravenous antibiotic medication for a resident by gathering a normal saline bag and a vial of Cefepime powder. After performing hand hygiene and donning gloves, Nurse #1 connected the antibiotic vial to the normal saline bag without cleaning the medication port of the saline bag with an alcohol swab. The nurse then mixed the antibiotic with the saline for administration. During an interview, Nurse #1 stated that she believed the medication port did not require cleaning with alcohol prior to mixing, despite the normal saline bag not being in a sterile package. The Director of Nursing (DON), who also serves as the Infection Preventionist, confirmed that facility procedure requires cleaning medication ports with an alcohol pad before connecting and mixing medications, a process intended to prevent bacterial contamination. The Administrator also confirmed that the expectation is for medication ports to be cleaned prior to mixing medications, in accordance with facility procedures.
Failure to Post Oxygen Use Signage in Resident Rooms
Penalty
Summary
The facility failed to post cautionary and safety signage outside of resident rooms indicating the use of oxygen for four residents who were receiving respiratory care. Resident #73, who was admitted with acute chronic respiratory failure with hypoxia, was observed on multiple occasions receiving oxygen therapy via nasal cannula at 5 liters per minute without any safety signage posted at the entrance to her room. Similarly, Resident #52, diagnosed with hypoxia and obstructive sleep apnea, had a physician order for oxygen therapy, but no cautionary signage was present in her room or on the unit. Resident #15, with diagnoses including chronic respiratory failure and COPD, was observed receiving supplemental oxygen therapy continuously, yet there was no signage indicating oxygen use in his room. Resident #37, who was receiving continuous oxygen therapy for COPD, also lacked appropriate safety signage outside his room. The Director of Nursing and the Administrator both stated that the facility did not post oxygen in use signs at resident doors, as they believed the tobacco-free campus signage at the main entrance sufficed. The facility's approach to signage was based on their status as a non-smoking campus, with signs posted at the entrance indicating this policy. However, the absence of specific oxygen use signage at resident rooms was a deficiency noted by surveyors, as it failed to meet safety requirements for indicating the presence of oxygen therapy in use within the facility.
Deficiencies in Hand Hygiene, Food Storage, and Staff Attire
Penalty
Summary
The facility failed to adhere to proper hand hygiene and food handling protocols during meal preparation and service. During a lunch meal tray line observation, a dietary aide was seen using the same pair of gloves for multiple tasks without performing hand hygiene, including plating French fries. This oversight was acknowledged by the kitchen supervisor, who confirmed that the dietary staff had previously received training on hand hygiene practices. In addition to hand hygiene issues, the facility did not maintain proper food storage practices. Observations revealed that several food items in the walk-in refrigerator and freezer were not properly sealed or labeled with dates of storage and use-by dates. Furthermore, the reach-in refrigerator lacked a working thermometer, making it impossible to monitor the temperature accurately. These storage concerns were not identified during the kitchen supervisor's daily rounds, nor during the Corporate Support Dietary Manager's spot checks. The facility also failed to ensure that dietary staff wore appropriate hair and beard restraints. During observations, a staff member was seen without a hair or beard cover while performing various kitchen tasks, and another staff member's beard cover was improperly positioned. The kitchen supervisor acknowledged her responsibility to monitor staff for proper use of hair and beard covers, but these issues were not addressed during her oversight.
Failure to Label Tube Feeding Formula
Penalty
Summary
The facility failed to ensure that an opened bottle of tube feeding formula was labeled with the date and time it was hung for a resident who required tube feeding. The resident, admitted with diagnoses including dysphagia and gastrostomy, had a physician's order for continuous tube feeding and water flushes. During an observation, it was noted that the bottle of tube feeding formula was not labeled with the date or time, which is a requirement for proper care and monitoring. Interviews with staff revealed that the nurse responsible for changing the tube feeding during the night shift did not label the bottle as required. The Unit Coordinator, who was covering for another nurse, was unaware of the labeling omission until it was pointed out. The Director of Nursing confirmed that the facility's protocol requires labeling the tube feeding bottle with the date and time whenever it is changed, highlighting a lapse in adherence to established procedures.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not donning the required Personal Protective Equipment (PPE) before entering a resident's room under transmission-based precautions. Specifically, a nurse aide entered the room of a resident who was under Enhanced Barrier Precautions (EBP) due to a feeding tube, without wearing a gown, although gloves were worn and changed according to the facility's handwashing policy. The facility's policy mandates the use of both gown and gloves during high-contact resident care activities, such as bathing, dressing, and changing briefs, to prevent the transmission of multidrug-resistant organisms. The nurse aide acknowledged the oversight, attributing it to a busy morning and forgetting the procedure, despite being aware of the EBP requirements. Interviews with the Infection Preventionist and the Director of Nursing confirmed that staff should wear both a gown and gloves when performing high-contact activities for residents under EBP. The Director of Nursing emphasized that all staff are expected to follow the precautions posted on residents' doors and adhere to the assigned PPE requirements.
Failure to Replace Nonfunctioning Air Conditioner
Penalty
Summary
The facility failed to replace a nonfunctioning air conditioner unit in a resident's room, compromising the resident's right to a safe, clean, comfortable, and homelike environment. The resident reported the issue to a nurse aide three weeks prior, who confirmed the air conditioner was not blowing cool air and promised to report it to the maintenance department. Despite this, the air conditioner remained unfixed, and the resident had to move to the commons area to stay cool. The maintenance director was only informed of the issue on a Friday, three days before the surveyor's observation, and determined the unit needed replacement. However, no immediate action was taken to provide temporary relief, such as offering a fan or a room change. The maintenance director did not record the issue in the maintenance repair log, and the director of nursing acknowledged that the facility should have provided alternative cooling options or a room change. The administrator expected timely action to address such issues, either through repair, replacement, or relocation of the resident. The outside temperatures during this period ranged from 77 to 91 degrees Fahrenheit, and the room temperature was recorded at 76 to 78 degrees Fahrenheit, indicating a potentially uncomfortable environment for the resident.
Failure to Provide Adequate Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident with hemiplegia and blindness, who was dependent on staff for assistance with activities of daily living (ADL). The resident, who was cognitively intact and required moderate assistance with personal hygiene, was observed to have one-inch-long fingernails with a brown substance underneath. Despite expressing the need for nail trimming to staff, the resident felt that staff did not have time to address her needs and was hesitant to ask for assistance due to fear of staff reactions. Interviews with staff revealed that nail care was supposed to be part of the resident's shower routine, but the assigned nurse aide did not trim the resident's nails, assuming the resident did not want them trimmed. The Director of Nursing and the Administrator were unaware of the resident's condition, indicating a lack of communication and oversight in ensuring the resident's personal hygiene needs were met. Eventually, another nurse aide trimmed the resident's nails after being prompted, but the deficiency in care had already been noted.
Exposed Insulin Syringe Left at Resident's Bedside
Penalty
Summary
The facility failed to maintain an environment free from potential hazards when an insulin syringe with the safety cap off and the needle exposed was found on a resident's bedside table. The resident, who was severely cognitively impaired and diagnosed with type 2 diabetes, had been administered insulin by a nurse who was covering due to a call out. The nurse admitted to administering the insulin but forgot to dispose of the used syringe properly, leaving it on the bedside table. Interviews with the Director of Nursing and the Administrator confirmed that the facility's protocol required used syringes and needles to be immediately disposed of in sharps containers located on each medication cart. The failure to follow this protocol resulted in the syringe being left at the resident's bedside, creating a potential hazard.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Pelican Health Randolph Llc | 1 mi | ★★★★★ | 15 | 0 |
| Brookdale Carriage Club Providence | 1.7 mi | ★★★★★ | 1 | 0 |
| White Oak Manor - Charlotte | 2 mi | ★★★★★ | 10 | 2 |
| The Sharon At Southpark | 2.6 mi | ★★★★★ | 0 | 0 |
| Briar Creek Health Center | 2.8 mi | ★★★★★ | 0 | 0 |
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