Inspection Reports for Oaks at Pooler

The purpose of this visit was to investigate intake #GA50006244.

No rule violations were cited as a result of this investigation.

Investigation started and completed on 2025-10-08 with no rule violations found.

The visit was conducted to investigate complaint intakes #GA50004646 and GA50004645 with an onsite visit made on 2025-08-14 and the investigation completed on 2025-08-15.

No rule violations were cited as a result of the investigations.

Investigation of complaint intakes #GA50004646 and GA50004645 found no rule violations.

The purpose of this visit was to investigate intake #GA50003574 with an onsite visit made on 6/24/2025.

The facility failed to ensure proper food handling practices as staff transferred grated cheese without hairnet and gloves, and failed to provide dessert to Resident #3 while serving other residents, indicating inadequate care and service.

Investigation was initiated based on intake #GA50003574. The complaint involved improper food handling and failure to provide dessert to a resident. The investigation included observations and interviews confirming these issues.

The visit was conducted to investigate intake #GA50002938, which involved a complaint regarding a resident eloping from the facility. The investigation started on 2025-04-28 and was completed on 2025-05-01, with an onsite visit on 2025-04-30.

The facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping, as evidenced by a defective alarm system on an emergency exit door that allowed Resident #1 to elope unnoticed. Resident #1 was found offsite and returned safely, but the door's locking mechanism was defective and did not trigger an alarm.

The investigation was initiated due to intake #GA50002938 concerning Resident #1 eloping from the memory care unit through a defective emergency exit door alarm on 2025-04-13. The resident was found by bystanders and returned safely. Staff interviews revealed unawareness of the defective locking mechanism and alarm system failure.

The purpose of this visit was to conduct an annual inspection of the facility.

No rule violations were cited as a result of this inspection.

The purpose of this visit was to investigate intake #GA50000830, which started on 2025-01-16 and was completed on 2025-01-28. The investigation was triggered by allegations including failure to provide a safe environment and issues with staff credentialing and training.

The facility failed to obtain satisfactory fingerprint background checks for some staff, lacked required training documentation for multiple employees, did not have an operational automated alert system for unauthorized entry, and employed certified medication aides not verified on the Georgia Certified Medication Aide Registry. Additionally, the facility failed to complete annual competency reviews for some medication aides.

The complaint investigation was initiated due to allegations that the facility failed to provide a safe environment after homeless men entered and stayed overnight without staff knowledge. Additional complaints included employing certified medication aides not verified on the registry and missing required staff training documentation.

The purpose of this visit was to investigate intakes #GA00252433 and #GA00252907. The investigation started and was completed on 12/26/2024 with an onsite visit.

No rule violations were cited as a result of this investigation.

Investigation of intakes #GA00252433 and #GA00252907 with no rule violations found.

The visit was conducted to investigate complaint intakes #GA00251298, #GA00251192, and #GA00251181, with the investigation starting on 2024-10-28 and completing on 2024-10-31.

No rule violations were cited as a result of this investigation.

Investigation of complaint intakes #GA00251298, #GA00251192, and #GA00251181 was completed with no rule violations found.

The purpose of this visit was to investigate intake #GA00249426, which involved concerns about grab bars in resident toilets and the locking mechanisms on exterior doors of resident rooms.

The facility failed to equip resident toilets with grab bars that meet accessibility needs for 6 of 7 sampled residents and failed to ensure that exterior doors of resident rooms were equipped with locks for 2 of 7 sampled residents. Several doors lacked proper locking mechanisms, and only a few apartments had external key locks.

The investigation was initiated due to intake #GA00249426, which included an allegation that a safe environment was not provided after a complainant found that Resident #8's apartment door could not be locked from the outside. Resident #8 was removed from the facility on 7/24/2024.

The visit was conducted to investigate intake #GA00247407 regarding allegations of misappropriation of funds involving Resident #1.

The facility failed to safeguard Resident #1's personal property, as Staff C admitted to stealing approximately $500 over a three-month period. Staff C was terminated for misconduct, and law enforcement was notified.

The complaint investigation was substantiated based on video evidence and staff admission. The family reported the theft, and law enforcement was notified. The complainant chose not to press charges as the facility terminated the responsible staff member.

The purpose of this visit was to investigate intakes #GA00244800, #GA00244781, and #GA00244737.

No rule violations were cited as a result of this investigation.

Investigation of three intakes (#GA00244800, #GA00244781, and #GA00244737) with no rule violations found.

The purpose of this visit was to investigate complaint intakes #GA00243625 and GA00243919.

The facility failed to ensure that Resident #1 received adequate and appropriate care and services in compliance with state law and regulations. Resident #1 was found outside the facility unsupervised, posing a safety risk, and was redirected back inside by staff with no injuries noted.

The visit was complaint-related, investigating intake #GA00243625 and GA00243919. Resident #1 was found outside the building unsupervised on 1/29/24, and staff interviews confirmed the resident was missing for up to 10 minutes before being returned safely.

The purpose of this visit was to investigate complaint intakes #GA00243221, #GA00242995, #GA00243307, and #GA00243583. The investigation started on 2024-02-05 and was completed on 2024-02-08, with an onsite visit on 2024-02-06.

The facility failed to include specific behaviors to be addressed with interventions in the care plan for Resident #1, despite allegations of inappropriate touching by Staff B. Interviews revealed conflicting statements about the accusation and the assessment process was incomplete due to the resident being taken out by family.

The investigation was complaint-related, triggered by multiple intakes. Resident #1 alleged that Staff B inappropriately touched him/her. Staff A and Staff B provided conflicting accounts regarding the accusation. Staff C and Staff G stated that Resident #1 was not assessed due to being taken out by family and not being in memory care.

The purpose of this visit was to investigate complaint intakes #GA00241373 and #GA00241272, with the investigation starting on 2023-11-28 and completed on 2023-11-29, including an onsite visit on 2023-11-29.

The facility failed to obtain a satisfactory fingerprint record check for one staff member and failed to ensure a resident's care plan addressed specific behavioral issues. Additionally, the facility did not operate in a manner respecting the personal dignity and human rights of a resident, involving an incident where a staff member searched the resident's adult brief without permission, leading to allegations of physical and sexual abuse. Law enforcement was notified and is investigating the incident.

The investigation was complaint-related, triggered by allegations of physical and sexual abuse of Resident #1 by a staff member (Staff C). Law enforcement was notified and is investigating. Incident reports and a police report document the events, including a staff member searching the resident's adult brief without permission and the resident's subsequent upset. No arrest order was issued, but the investigation is ongoing.

The purpose of this visit was to investigate intake #GA00239628.

No rule violations were cited as a result of this investigation.

Investigation of intake #GA00239628 with no rule violations found.

The purpose of this visit was to investigate intake #GA00237627 and #GA00237353.

The facility failed to report within 24 hours a serious incident involving a resident (Resident #1) where Staff B pushed the resident after being hit and bitten. The incident was not reported to the Department as required.

The visit was complaint-related to investigate intake #GA00237627 and #GA00237353. The incident involved Staff B pushing Resident #1 after being hit and bitten by the resident. The incident was not reported to the Department as required.

The purpose of this visit was to investigate intake #GA00236397.

No rule violations were cited as a result of this investigation.

Investigation of intake #GA00236397 with no rule violations found.

The purpose of this visit was to investigate complaint intakes #GA00234009 and #GA00234044 regarding the facility's care and services.

The facility failed to have a full-time administrator, maintain personnel files, provide sufficient staff assistance with eating, hygiene, and transfers, maintain a clean and safe environment, update care plans to reflect residents' changing needs, and provide adequate care and services to Resident #1. Significant delays in emergency call responses and poor resident care were documented.

The visit was complaint-related, investigating allegations that residents were not being fed, Resident #1 was not assisted with hygiene or transfers, the environment was unsanitary, and care plans were not updated. The complaint was substantiated based on observations, interviews, and record reviews.

The purpose of this visit was to investigate intake #GA00232019.

The facility failed to ensure personnel files included evidence of satisfactory fingerprint record checks, training and skills competency determinations, and that medication aides were listed in good standing on the Georgia Certified Medication Aide Registry for sampled staff.

The visit was complaint-related, investigating intake #GA00232019.

The purpose of this visit was to investigate intake GA00224356.

No rule violations were cited as a result of this investigation.

Investigation of intake GA00224356 with no rule violations cited.

The purpose of this visit was to investigate intakes #GA0022035 and GA00220875 and conduct the compliance inspection.

The facility failed to include signed medical orders impacting end of life care, such as Do Not Resuscitate (DNR) orders, in the resident's file for 1 of 6 sampled residents (Resident #6). Resident #6 was found unresponsive and deceased with no documented DNR in the file despite hospital documentation and discussions with the resident's family.

Investigation was triggered by intakes #GA0022035 and GA00220875. The complaint was substantiated by findings that the facility did not have signed DNR orders in the resident's file despite hospital documentation and family instructions.

The purpose of this review is to monitor COVID 19 cases and assess infection control processes.

The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.

The purpose of this visit was to investigate complaints #GA00198202 and GA00198295.

No rule violations were cited as a result of this investigation.

Investigation was conducted following complaints #GA00198202 and GA00198295; no violations were found.

The purpose of this visit was to investigate complaint #GA00197492.

No rule violations were cited as a result of this investigation.

Investigation of complaint #GA00197492 resulted in no rule violations.

The purpose of this visit was to investigate complaint numbers GA00196912, GA00197107, and GA00197120.

No rule violations were cited as a result of this investigation.

Investigation of complaints GA00196912, GA00197107, and GA00197120 with no rule violations found.

The purpose of this survey was to conduct a paperwork follow-up to the 1/23/19 inspection.

Based on a review of documentation submitted by the facility, the violation cited on the previous inspection has been corrected.

The purpose of this visit was to conduct the compliance inspection and to investigate complaint GA00194037.

The facility failed to comply with emergency preparedness requirements, specifically related to fire drills. Fire drills conducted between 1/1/18 and 1/19/19 took longer than the allowed 13 minutes to evacuate residents, with some drills taking up to 26 minutes due to evacuating residents needing more assistance.

Investigation of complaint GA00194037 regarding emergency preparedness and fire drill evacuation times.

The purpose of this visit was to investigate complaint #GA00192377.

No rule violations were cited as a result of this investigation.

Investigation was begun on 2018-11-05, an on-site visit was made on 2018-11-06, and the investigation was completed on 2018-11-07. No rule violations were found.

The purpose of this visit was to conduct a follow-up to the 3/22/18 inspection.

No rule violations were cited as a result of this inspection.

The purpose of this visit was to investigate intake #GA #00190543, involving an incident where Resident #1 was injured during transport in the facility van on 7/31/18.

The facility failed to provide adequate and appropriate care and services for Resident #1 after an incident where the resident's wheelchair tipped backward in the van causing a head injury. The incident was not properly documented, medical intervention was lacking, and the resident's family was not notified in a timely manner.

Investigation of intake #GA #00190543 regarding Resident #1's injury during transport on 7/31/18. The complaint was substantiated as the facility failed to document the incident, provide medical intervention, and notify the family timely.

The purpose of this visit was to investigate self reported incident # GA00188463.

No rule violations were cited as a result of this investigation.

Investigation of self reported incident # GA00188463 with no rule violations cited.

The purpose of this visit was to investigate complaint # GA00187436 regarding alleged abuse.

The facility failed to ensure that residents were free from mental, verbal, and physical abuse. Specifically, Resident #1 reported verbal and physical abuse by Staff B, which was corroborated by witness statements.

Complaint investigation of abuse allegations involving Staff B. Resident #1 reported verbal and physical abuse, supported by witness interviews. The complaint was substantiated as the facility failed to prevent abuse.

The purpose of this visit was to investigate a self-reported incident GA00186598.

No rule violations were cited as a result of this investigation.

Investigation of self-reported incident GA00186598 with no rule violations found.

The purpose of this visit was to investigate complaint #GA00186079 with on-site visits made on 2018-03-13 and 2018-03-21, and the investigation completed on 2018-03-22.

The facility failed to ensure staff received hands-on training within the first 60 days of employment on transferring residents using gait belts and draw sheets, and failed to review and update the written care plan for Resident #1 regarding transfers. Resident #1 suffered two fractures and a laceration related to improper transfers, with inadequate documentation and explanation provided to the responsible party.

The investigation was initiated due to complaint #GA00186079. The complaint involved inadequate staff training on resident transfers, resulting in Resident #1 sustaining a spiral tibia fracture and fibular fracture on 2017-12-22, and a subsequent open tibial fracture with displacement and laceration on 2018-02-14. The responsible party stated they never received an explanation of how the injuries occurred and that transfer procedures were not addressed in the care plan.

The purpose of this visit was to investigate complaint GA 00184328.

No rule violations were cited during the investigation.

Complaint GA 00184328 was investigated and found to have no rule violations.

The purpose of this visit was to conduct the annual inspection of the facility.

The facility failed to ensure fire evacuation drills were rehearsed in compliance with fire safety standards, as evidenced by incomplete fire drill records and staff interview indicating a shortage of fire drills.

The visits on 07-11-2017 and 08-14-2017 were conducted to investigate complaint #GA00178370.

The facility was found to be providing nursing services that are prohibited proxy caregiver services, specifically an unlicensed staff member administered morphine to a resident.

Complaint #GA00178370 was investigated during visits on 07-11-2017 and 08-14-2017. The complaint was substantiated by findings of prohibited proxy caregiver services.

The purpose of this visit was to investigate complaint #GA00173043.

No rule violations were cited as a result of this investigation.

Complaint #GA00173043 was investigated and found to have no rule violations.

The purpose of this visit was to investigate complaint #GA00170353.

The facility failed to provide protective care and watchful oversight for one sampled resident who was able to exit the facility through an open window and walk approximately 1,500 feet down the street before staff located the resident.

Complaint #GA00170353 was investigated and substantiated based on the finding that the resident was able to leave the facility unsupervised.