Inspection Reports for Oaks at Evans
353 N Belair Rd, Evans, GA 30809, United States, GA, 30809
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 24, 2021, found no deficiencies. Earlier inspections showed some issues, including substantiated medication administration errors in 2019 and staffing plan deficiencies in 2021. The main themes of deficiencies involved medication management errors and staffing shortages, with medication errors leading to hospital transport in one case and substantiated complaints about narcotic mishandling. Complaint investigations were mostly substantiated when deficiencies were found, while several other investigations found no violations. The facility’s record shows some improvement, with the latest inspection free of deficiencies after prior issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00217075.
Complaint Details
Investigation of intake #GA00217075 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Date: Mar 12, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00211856, which began on 2021-02-22 and was completed on 2021-03-12.
Complaint Details
Investigation of intake GA00211856. Interviews indicated substantiated staffing shortages and overworked staff.
Findings
The facility failed to maintain accurate staffing plans that account for residents' specific needs and monthly work schedules, resulting in insufficient staff coverage, particularly on night shifts. Interviews revealed staff shortages, overworked employees, and inadequate staffing for cleaning and resident care.
Deficiencies (1)
Failed to maintain accurate staffing plans accounting for residents' needs and monthly work schedules, including relief workers, showing planned and actual coverage for each day and night.
Report Facts
Resident census: 28
Dates of time sheets reviewed: 3
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 22, 2020
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited during the inspection completed on 2020-01-22.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 8, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00199163 regarding medication administration errors at the facility.
Complaint Details
Investigation of intake #GA00199163 found substantiated medication administration errors where Resident #2 was given Resident #1's medications, resulting in hospital transport. Staff interviews confirmed the error and that Resident #1 did not receive medications.
Findings
The facility staff failed to follow the written doctor's orders for two residents, resulting in Resident #2 being given Resident #1's medications by mistake and requiring hospital transport. Interviews confirmed medication administration errors and that Resident #1 did not receive his/her medications that night.
Deficiencies (1)
Facility staff failed to follow the written doctor's order for medication administration for 2 residents, leading to Resident #2 receiving Resident #1's medications by mistake.
Report Facts
Date of incident: Aug 26, 2019
Date of EMS call: Aug 25, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Staff who administered wrong medications to Resident #2 without checking the medication cup | |
| Staff A | Staff who stated Resident #1 did not get medications that night |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 25, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00197401.
Complaint Details
Investigation of intake #GA00197401 with no violations found.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 25, 2019
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a healthcare facility inspection conducted at Morningside of Evans.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 5, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00192355 regarding medication management and resident care at the assisted living community.
Complaint Details
The visit was complaint-related, investigating medication theft and improper narcotic administration. The complaint was substantiated based on findings of medication tampering, theft of 206 prescription pills, and staff not following physician orders.
Findings
The investigation found that the facility failed to provide adequate and appropriate care to 5 sampled residents by improperly managing narcotic medications, including medication tampering, giving medications at incorrect times, and medication theft. Several residents received acetaminophen instead of prescribed narcotics, and staff failed to follow doctor's orders.
Deficiencies (1)
Failure to ensure residents received adequate and appropriate care related to medication management, including tampering and incorrect administration of narcotic medications for 5 sampled residents.
Report Facts
Missing prescription pills: 206
Medication errors: 4
Sampled residents: 5
Quantity of medication: 20
Dates of medication incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in medication error findings for giving narcotics before prescribed times and signing off medications not given. | |
| Staff B | Reported Staff C's medication errors and confirmed physician orders. | |
| Staff A | Discovered medication theft and reported missing pills. | |
| Staff D | Counted narcotics and identified medication problems. | |
| Staff E | Counted narcotics and identified medication problems. | |
| Staff F | Reported concerns about Staff C's medication administration practices. | |
| AA | Communicated with facility regarding Resident #1's medication refill issues. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 27, 2018
Visit Reason
The visit was conducted to perform the annual inspection and to investigate a self-reported complaint #GA00185133.
Complaint Details
Investigation of self-reported complaint #GA00185133 was part of the inspection.
Findings
The report documents the completion of the annual inspection and complaint investigation started on 2018-02-20 and completed on 2018-02-27. No specific findings or deficiencies are detailed on this page.
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