Inspection Reports for The Oaks Nursing Home, Inc
777 NURSING HOME ROAD, MARSHALLVILLE, GA, 31057
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 30, 2025, identified deficiencies related to fire safety, including missing evidence of fire alarm sensitivity testing and unclean sprinkler heads in the laundry wing. Earlier inspections showed a mixed pattern, with prior deficiencies involving care planning accuracy, food preparation, and storage practices, as well as some fire safety and electrical equipment issues. Complaint investigations were mostly unsubstantiated, though one complaint led to findings about inaccurate resident assessments and incomplete care plan revisions. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility has shown some improvement in correcting prior deficiencies, but recent fire safety issues indicate ongoing attention is needed in that area.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
97% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Life Safety
Census: 58
Capacity: 60
Deficiencies: 2
Date: Jun 30, 2025
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in compliance with fire safety requirements, specifically failing to provide evidence of fire alarm sensitivity testing and failing to maintain clean sprinkler heads in the laundry wing. These deficiencies affect residents and staff throughout the facility.
Deficiencies (2)
Failed to provide evidence of fire alarm sensitivity testing as required every 2 years in addition to the annual fire alarm inspection.
Failed to maintain clean sprinkler heads; three sprinkler heads inside and just outside the laundry room were covered with excessive dust.
Report Facts
Census: 58
Total Capacity: 60
Date of Survey: Jun 30, 2025
Number of sprinkler heads with excessive dust: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm sensitivity testing and sprinkler head cleanliness during facility tour |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
A State Licensure survey was conducted at The Oaks Nursing Home by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health, from June 16, 2025, through June 19, 2025.
Findings
The survey revealed that no State Health deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Date: Jun 19, 2025
Visit Reason
A standard survey was conducted from June 16, 2025, through June 19, 2025, including investigation of Complaint Intake Number GA00254979, to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Complaint Details
Complaint Intake Number GA00254979 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance due to inaccurate coding of Minimum Data Set (MDS) assessments for two residents, failure to revise a care plan for use of a bed cradle for one resident, and omissions that could lead to inaccurate assessment and care planning.
Deficiencies (2)
Failed to ensure two of 26 sampled residents had accurate MDS assessments, specifically failure to reflect use of clip alarms and chair alarms.
Failed to revise the care plan of one resident for the use of a bed cradle, risking inadequate treatment to prevent skin breakdown.
Report Facts
Number of sampled residents: 26
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Acknowledged inaccuracies in MDS assessments and care plan revisions | |
| Wound Care Nurse | Provided assessment and treatment notes related to resident with bed cradle care plan deficiency |
Inspection Report
Follow-Up
Census: 57
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the January 21, 2024 Recertification Survey.
Findings
All deficiencies cited in the January 21, 2024 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Census: 57
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the January 21, 2024 Recertification Survey.
Findings
All deficiencies cited in the January 21, 2024 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Original Licensing
Deficiencies: 3
Date: Jan 21, 2024
Visit Reason
The inspection was conducted as a State Licensure survey at The Oaks Nursing Home from January 19 through January 21, 2024, to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to ensure staff followed food recipes for preparing pureed foods, which potentially compromised the nutritive value of meals for residents on a puree diet. Additionally, the facility did not properly label and date items in dry storage, freezers, and refrigerators, and cell phones were found in clean storage areas, posing risks to food safety and resident health.
Deficiencies (3)
Failure to ensure staff followed food recipes for preparing pureed foods for four residents receiving a puree diet.
Failure to label and date items in dry storage area, freezers, and refrigerators with use-by or expiration dates.
Failure to ensure cell phones were not left in clean storage areas of the kitchen.
Report Facts
Residents receiving puree diet: 4
Residents receiving oral diet: 57
Total residents receiving oral diet: 58
Dates of inspection: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor EE | Dietary Supervisor | Reported recipes were not used by dietary staff and has over 30 years of cooking experience |
| Dietary Aide II | Dietary Aide | Observed preparing pureed tuna salad without following a recipe |
| Certified Dietary Manager | Certified Dietary Manager | Reported on puree process and kitchen observations, provided recipe book not current |
| Dietary Supervisor DD | Dietary Supervisor | Reported lack of current menus signed by Registered Dietitian and acknowledged food labeling issues |
| Dietary Aide BB | Dietary Aide | Responsible for cleaning and stocking, unaware of food dating requirements |
| Dietary Aide CC | Dietary Aide | Reported leftovers should be stored with in-date and use-by date and kept for three days |
Inspection Report
Routine
Census: 58
Deficiencies: 3
Date: Jan 21, 2024
Visit Reason
A standard survey was conducted from January 19, 2024, through January 21, 2024, including investigation of two complaint intake numbers which were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00241142 and GA00241669 were investigated and found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to clean respiratory equipment per MD orders, failure to follow recipes for pureed foods, and failure to properly label and date food items in storage areas, as well as improper storage practices such as cell phones in clean areas.
Deficiencies (3)
Failed to monitor and clean respiratory equipment per MD orders for one resident (R26).
Failed to ensure staff followed food recipes for preparing pureed foods for four residents.
Failed to ensure food items in dry storage, freezers, and refrigerators were labeled and dated with use-by or expiration dates; cell phones were left in clean storage areas.
Report Facts
Residents present: 58
Sample size: 24
Residents on pureed diet: 4
Containers of tea: 5
Days for leftover food discard: 2
Days for refrigerator food use: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Registered Nurse Supervisor | Acknowledged dirty oxygen concentrator and filter for resident R26 |
| Director of Nursing | Director of Nursing | Acknowledged oxygen concentrator was not cleaned daily per MD orders |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed staff were supposed to monitor oxygen concentrator daily |
| EE | Dietary Supervisor | Reported recipes were not used by dietary staff for pureed foods |
| DD | Dietary Supervisor | Reported lack of current menus signed by Registered Dietitian and acknowledged unlabeled food items |
| CDM | Certified Dietary Manager | Reported on food preparation practices, unlabeled food items, and cleaning responsibilities |
| BB | Dietary Aide | Reported cleaning duties and lack of awareness about labeling food items |
| CC | Dietary Aide | Reported leftovers storage and labeling requirements |
Inspection Report
Life Safety
Census: 58
Capacity: 60
Deficiencies: 0
Date: Jan 20, 2024
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The Oaks Nursing Home was found to be in substantial compliance with the requirements of 42 CFR 483.73 for emergency preparedness and 42 CFR Subpart 483.90(a) for Life Safety from Fire, including compliance with NFPA 101 Life Safety Code 2012 edition.
Report Facts
Census: 58
Total Capacity: 60
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 7, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from April 5, 2022 through April 7, 2022 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from April 5, 2022 through April 7, 2022.
Inspection Report
Routine
Census: 59
Deficiencies: 0
Date: Apr 7, 2022
Visit Reason
A standard survey was conducted at Oaks Nursing Home, Inc. from April 5, 2022, through April 7, 2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 59
Capacity: 60
Deficiencies: 0
Date: Apr 6, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.
Inspection Report
Routine
Census: 58
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Capacity: 4
Deficiencies: 0
Date: May 5, 2020
Visit Reason
A walk-through virtual tour was conducted of Unit I, an addition of four private rooms at The Oaks Nursing Home.
Findings
The 4-bed unit was determined to be in compliance with State requirements.
Report Facts
Total unit beds: 4
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 29, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey found that all previously cited deficiencies had been corrected.
Inspection Report
Routine
Census: 55
Deficiencies: 0
Date: Jan 10, 2019
Visit Reason
A standard survey was conducted at The Oaks Nursing Home from January 7, 2019 through January 10, 2019 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 55
Capacity: 60
Deficiencies: 1
Date: Jan 8, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to provide proper ventilation for the gas-fired hot water heater, which could place residents and staff at risk in the event of a fire. Specifically, supply air vents to the boiler room were covered with plywood, confirmed by staff during the inspection.
Deficiencies (1)
Failed to provide proper ventilation for the gas fired hot water heater; supply air vents to the boiler room were covered with plywood.
Report Facts
Residents at risk: 10
Census: 55
Total licensed beds: 60
Inspection Report
Routine
Census: 59
Deficiencies: 0
Date: Jan 4, 2018
Visit Reason
A standard survey was conducted at Oaks Nursing Home from January 2, 2018 through January 4, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 43, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 59
Capacity: 60
Deficiencies: 0
Date: Jan 2, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The Oaks Nursing Home was found in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards during the survey.
Report Facts
Certified Beds: 60
Census: 59
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 1, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey found that all previously cited deficiencies had been corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 29, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the recertification survey on 2017-03-16.
Findings
All deficiencies cited during the recertification survey conducted on 2017-03-16 were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 53
Capacity: 60
Deficiencies: 1
Date: Mar 13, 2017
Visit Reason
A Life Safety Code survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and electrical equipment standards.
Findings
The facility was found not in substantial compliance due to improper use of electrical equipment and wiring, specifically the use of multiplug adapters in resident rooms, which could place residents at risk of fire or electrocution.
Deficiencies (1)
Use of multiplug adapters in resident rooms A-2, A-3, A-4, and C-2, failing to comply with NFPA 70 and NFPA 99 electrical equipment and wiring standards.
Report Facts
Residents at risk: 4
Census: 53
Certified Beds: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff M confirmed findings during the tour |
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