Inspection Reports for Oaks at Snellville
2078 Scenic Hwy S, Snellville, GA 30078, United States, GA, 30078
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 10, 2025, identified a deficiency related to serving shellfish to a resident with a documented shellfish allergy, though the resident did not ingest the shellfish or require hospitalization. Earlier inspections showed a pattern of deficiencies primarily involving medication management, resident care including bathing and supervision, staff training, and reporting requirements. Several substantiated complaints involved medication errors causing harm, failure to report incidents to authorities, and inadequate personal care services. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent findings suggest ongoing challenges in care and reporting, with no clear pattern of improvement or worsening over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
The purpose of this visit was to investigate complaint intake# GA50003091, which began on 2025-06-10 with an unannounced on-site visit and was completed on 2025-06-14.
Complaint Details
Complaint intake GA50003091 was reported by AA on 2025-04-20 regarding Resident #1 being served shrimp scampi despite a known shellfish allergy. The resident did not ingest the shellfish and was not hospitalized. The investigation confirmed the facility was aware of the allergy but agency staff unfamiliar with dietary restrictions served the shellfish.
Findings
The facility failed to adhere to practices and procedures that support dignity, respect, and choice in a safe environment for one sampled resident (Resident #1) who was erroneously served shellfish despite documented allergies. The resident did not ingest the shellfish and did not require hospitalization.
Deficiencies (1)
Failure to implement policies and procedures supporting dignity, respect, choice, independence, and privacy for Resident #1, evidenced by serving shellfish to a resident with documented shellfish allergy.
Report Facts
Dates related to complaint and investigation: Apr 20, 2025
Dates related to complaint and investigation: Jun 10, 2025
Dates related to complaint and investigation: Jun 14, 2025
Resident move-in date: Mar 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding serving shellfish to Resident #1 and awareness of dietary restrictions | |
| Staff B | Interviewed about dietary restrictions, diet order forms, and meal service procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
The purpose of this visit was to investigate intakes GA000252437, GA00252669, and GA0000293.
Complaint Details
Investigation of complaint intakes GA000252437, GA00252669, and GA0000293 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00250448.
Complaint Details
Investigation of intake# GA00250448 with no rule violations cited.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00247876 with an on-site visit made to the facility on 7/15/2024.
Complaint Details
Investigation of intake #GA00247876; no rule violations were found.
Findings
The investigation was completed on 7/15/2024 and no rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 20, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00246430.
Complaint Details
Investigation of intake #GA00246430 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 6, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00246146 and conduct the compliance inspection.
Complaint Details
Investigation of intake #GA00246146 was conducted with no rule violations cited.
Findings
An on-site visit was made to the facility on 5/6/24 and the investigation was completed on 5/9/24. No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 12, 2024
Visit Reason
The purpose of this offsite/desk review was to investigate complaint intakes #GA00243805, #GA00243817, and #GA00244324 received by the Department.
Complaint Details
Investigation was complaint-related based on intakes received on 2/13/24, 2/14/24, and 2/29/24. The abuse allegation involved Staff B pushing Resident #1 causing injury. The incident was reported to law enforcement by hospice staff, but the facility did not report it to law enforcement, stating the family did not wish to press charges.
Findings
The facility failed to report allegations of abuse of a resident to law enforcement as required by the Long-Term Care Resident Abuse Reporting Act. Surveillance showed Staff B pushing Resident #1 roughly into bed causing the resident to hit his/her head on the wall. The incident was reported to law enforcement by hospice staff, but the facility did not report it, citing the family did not wish to press charges.
Deficiencies (1)
Facility failed to report to police any allegations of abuse of a resident in accordance with the Long-Term Care Resident Abuse Reporting Act.
Report Facts
Intake dates: 3
Resident age: 93
Incident report time: 1142
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Stated a report of the incident was made to the Department but not to law enforcement | |
| Staff B | Physically pushed Resident #1 into bed causing injury | |
| FF | Reported the incident to the facility with a copy of the video surveillance | |
| GG | Stated hospice made the report to law enforcement on his/her behalf and did not press charges | |
| HH | Reported the incident to law enforcement on 2/14/24 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 27, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238190. An on-site visit was made to the facility on 9/27/23 as part of the investigation that started on 9/25/23 and was completed on 10/02/23.
Complaint Details
The investigation was initiated due to intake #GA00238190 concerning medication errors and inadequate personal care for Resident #1. The complaint was substantiated based on record reviews and interviews.
Findings
The facility failed to ensure timely refills of prescribed medications for Resident #1, resulting in missed doses of Sertraline and Eliquis. Additionally, the facility failed to provide adequate personal care services, specifically showers, as Resident #1 did not receive showers as scheduled and documentation of refusals was incomplete.
Deficiencies (2)
Failed to ensure that refills of prescribed medications were obtained timely, causing interruptions in routine dosing for Resident #1.
Failed to ensure each resident received adequate and appropriate care and services, including failure to provide scheduled showers to Resident #1.
Report Facts
Missed doses of Sertraline: 7
Missed doses of Eliquis: 8
Scheduled showers per week: 3
Actual showers received in July 2023: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding medication errors and shower refusals; acknowledged responsibility for medication availability and documentation. | |
| Staff B | Interviewed regarding Resident #1's shower schedule and refusals. | |
| AA | Interviewed regarding notification about medication shortage and pharmacy refill. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 29, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237974. An on-site visit was made to the facility on 8/29/23. The investigation started on 8/28/23 and was completed on 8/31/23.
Complaint Details
Investigation was initiated due to intake #GA00237974 regarding medication errors for Resident #1. The complaint was substantiated as Resident #1 received incorrect warfarin dosage multiple times, resulting in hospitalization for warfarin toxicity and hemothorax.
Findings
The facility failed to ensure proper oversight and medication management for Resident #1, resulting in administration of incorrect warfarin dosage (2.5 mg instead of 2 mg) on multiple dates in July 2023. This led to Resident #1 being hospitalized with hemothorax and warfarin toxicity. The facility also failed to properly dispose of discontinued medications and lacked nurse oversight during medication administration.
Deficiencies (3)
Facility failed to ensure governing body provided oversight in compliance with rules for Resident #1, including failure to remove discontinued warfarin 2.5 mg from medication cart leading to medication errors.
Facility failed to properly dispose of unused medication according to FDA and EPA guidelines for Resident #1.
Facility failed to ensure each resident received adequate and appropriate care and services, resulting in medication errors and harm to Resident #1.
Report Facts
Medication error dates: 12
Medication dosage change date: Jul 14, 2023
Investigation start date: Aug 28, 2023
Investigation completion date: Aug 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported medication error, uploaded prescription to electronic health record, did not notify CMAs of dosage change, initiated investigation, spoke with Staff C, placed Staff C on suspension | |
| Staff B | Corporate Nurse / Wellness Director | Worked twice weekly, responsible for MAR reviews, medication refills, supervision, incident reports, managed resident care, did not notify CMAs of dosage change |
| Staff C | Certified Medication Aide (CMA) | Administered incorrect warfarin dosage, unaware of dosage change, signed MAR incorrectly, placed on suspension |
| Staff E | Received warfarin 2 mg medication, did not remove discontinued warfarin 2.5 mg from medication cart, worked third shift |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237054. An on-site visit was made to the facility on 7/26/23, with the investigation starting on 7/26/23 and completed on 8/2/23.
Complaint Details
Investigation was initiated based on intake #GA00237054. The complaint was investigated through on-site and telephone interviews with staff regarding the administrator's absence and delegation of responsibilities.
Findings
The facility failed to ensure that a designated qualified responsible staff was present to act on the administrator's behalf and carry out duties during the administrator's absence. Staff interviews revealed confusion about who was in charge during the administrator's absence, with the designated staff unaware of their responsibilities.
Deficiencies (1)
Facility failed to ensure a designated qualified responsible staff was present to act on the administrator's behalf during the administrator's absence.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 6, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235789. An on-site visit was made to the facility on 2023-06-29. The investigation started on 2023-06-26 and was completed on 2023-07-06.
Complaint Details
Investigation of intake #GA00235789 was conducted with an on-site visit on 2023-06-29. The investigation was initiated on 2023-06-26 and completed on 2023-07-06.
Findings
The facility failed to ensure that Resident #1 had a physical examination dated within 30 days prior to admission and that the examination form was fully completed including tuberculosis screening. Additionally, the facility failed to have a written care plan addressing specific behaviors and interventions for Resident #1, including assistance with transfers.
Deficiencies (2)
Failed to ensure Resident #1 had a physical examination dated within 30 days prior to admission and completed tuberculosis screening documentation.
Failed to have a written care plan addressing specific behaviors and interventions for Resident #1, including assistance with transfers.
Report Facts
Resident admission date: Apr 30, 2023
Individual service plan date: May 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1 physical examination and care plan deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00233733. An on-site visit was made to the facility on 4/11/23. The investigation started on 4/10/23 and was completed on 4/20/23.
Complaint Details
Investigation of intake #GA00233733 regarding failure to provide adequate bathing care to Resident #1. Resident and staff interviews indicated inconsistent shower provision and documentation. Resident sometimes refused showers, but staff did not always follow up appropriately.
Findings
The facility failed to ensure that Resident #1 received adequate and appropriate care and services, specifically related to bathing assistance. Documentation showed no confirmation that scheduled showers were completed, and interviews revealed inconsistent shower provision and documentation, with some refusals by the resident.
Deficiencies (1)
Facility failed to ensure Resident #1 received scheduled showers as required by the individualized service plan, with no documentation confirming completion and inconsistent staff follow-up.
Report Facts
Number of sampled residents: 3
Date of Resident #1 admission: Jun 6, 2022
Date of physician evaluation: Jun 15, 2022
Date of ISP: Mar 28, 2023
Date of shower task report: Aug 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding shower documentation and tracking | |
| Staff B | Interviewed regarding shower refusals and documentation | |
| Staff C | Interviewed regarding shower refusals and documentation | |
| Staff E | Interviewed regarding shower refusals and family contact | |
| Staff F | Interviewed regarding shower refusals and offers | |
| AA | Interviewed as visitor/family regarding shower observations |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 8, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00230281 and conduct the compliance inspection at Oaks at Snellville. The onsite visit was made on 3/8/23, with the investigation starting on 3/6/23 and completed on 3/28/23.
Complaint Details
The visit was complaint-related, investigating intake GA00230281. The investigation included review of staff training, health screenings, meal quality, and medication administration practices.
Findings
The facility failed to ensure employees completed required training and health screenings, failed to provide well-balanced and properly prepared meals for residents, and failed to ensure residents received timely medication administration and appropriate care due to inadequate staffing.
Deficiencies (4)
Facility failed to ensure employees involved with personal services had at least sixteen hours of training per year for 1 of 6 sampled staff (Staff F).
Facility failed to ensure each employee received tuberculosis screening and physical examination within 12 months prior to employment for 1 of 6 sampled staff (Staff E).
Facility failed to provide well-balanced, nutritious meals sufficient in proper form and consistency for 2 of 2 sampled residents (Resident #2 and Resident #3).
Facility failed to ensure each resident received adequate, appropriate care and services in compliance with federal and state law for 3 of 6 sampled residents (Resident #2, Resident #4, Resident #7), including timely medication administration.
Report Facts
Sampled staff: 6
Sampled residents: 6
Residents with care deficiencies: 3
Residents with meal deficiencies: 2
Training hours required: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Failed to complete required 16 hours of training in 2022 | |
| Staff E | Did not receive tuberculosis screening and physical examination within 12 months prior to employment | |
| Staff L | Facility Cook | Responsible for food preparation; involved in meal quality deficiencies |
| Staff A | Interviewed regarding staff training, meal quality complaints, medication administration, and staffing issues | |
| Staff C | Interviewed about resident complaints and food quality issues | |
| Staff G | Interviewed about medication administration delays and staffing coverage | |
| Staff H | Interviewed about food quality issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00225159. An on-site visit was made to the facility on 7/19/22. The investigation started on 7/18/22 and was completed on 7/21/22.
Complaint Details
Investigation of intake #GA00225159 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00219872.
Complaint Details
Investigation of intake #GA00219872 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 17, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00215603, #GA00215807, and #GA00215815. The investigation was opened on 2021-10-26 and completed on 2021-12-17.
Complaint Details
The investigation was complaint-driven based on intake numbers #GA00215603, #GA00215807, and #GA00215815. The complaint involved failure to provide required employee training and failure to report a serious incident involving Resident #3, who fell and later expired. The complaint investigation was substantiated by the findings.
Findings
The facility failed to ensure that all employees received required work-related training within the first 60 days of employment, as evidenced by Staff E's lack of training. Additionally, the facility failed to report a serious incident involving Resident #3 within 24 hours as required.
Deficiencies (2)
Failure to ensure that any person working at the home as an employee received work-related training within the first 60 days of employment.
Failure to report a serious incident involving a resident using the complaint intake system within 24 hours following the occurrence or learning of the incident.
Report Facts
Incident date: Jun 27, 2021
Resident expiration date: Oct 28, 2021
Staff E hire date: May 26, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Employee who did not complete required work-related training | |
| Staff G | Interviewed and stated Staff E did not complete training and no report was sent to the Department | |
| Staff B | Interviewed and stated no discharge information was received for Resident #3 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 14, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00219637. An on-site visit was made to the facility on 12/14/21, with the investigation completed on 12/22/21.
Complaint Details
Investigation was initiated due to intake #GA00219637. The complaint was substantiated by findings that personnel files were not available and required documentation for Staff B was missing.
Findings
The facility failed to ensure that personnel files for each employee were maintained either in the home or available for inspection within one hour of request and for three years following the employee's departure. Specifically, the file for Staff B was not accessible due to management changes, and requested documentation including resignation letter, criminal background check, and residents' rights and abuse training for Staff B was not provided as of 12/22/21.
Deficiencies (1)
Facility failed to ensure personnel files were maintained and available for inspection for Staff B.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Personnel file not available and missing required documentation. | |
| Staff K | Interviewed and stated the personnel file for Staff B was not accessible due to management changes. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 10, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00217753. An on-site visit was made to the facility on 2021-10-12. The investigation started on 2021-10-11 and was completed on 2021-11-10.
Complaint Details
The investigation was initiated due to intake #GA00217753 regarding Resident #1 eloping from the facility on 2021-09-14. The resident left through an unlocked kitchen exit door without staff noticing. Staff searched for the resident, police were notified, and the resident was found and returned safely. Resident #1 was moved to memory care for safety and given a 30-day notice due to elopement.
Findings
The facility failed to provide supervision consistent with the residents' needs, as evidenced by Resident #1 eloping from the facility through an unlocked kitchen exit door without staff awareness. Resident #1 was found by police and returned safely, with no injuries observed.
Deficiencies (1)
Facility failed to provide supervision consistent with residents' needs, allowing Resident #1 to elope through an unlocked kitchen exit door without alarm or staff awareness.
Report Facts
Date of elopement incident: Sep 14, 2021
Staff working during incident: 4
Time resident was away: 45
Time resident returned: 1900
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Contacted by Resident #1's family, coordinated search and police notification, involved in incident report and resident care. | |
| Staff B | Caregiver | Worked on 9/14/21, last saw Resident #1 in dining room, alerted staff via walkie talkie about elopement. |
| Staff C | Caregiver | Worked on 9/14/21, searched for Resident #1 in community, last saw Resident #1 getting on elevator. |
| Staff D | Medication Aide | Worked on 9/14/21, last saw Resident #1 at dinner, reported kitchen exit door unlocked, searched for Resident #1, called police. |
| Staff E | Caregiver in memory care | Worked on 9/14/21 in memory care unit. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 8, 2021
Visit Reason
The inspection was conducted to investigate intake #GA00214777, which began on 2021-06-14 and was completed on 2021-07-08.
Complaint Details
The investigation was complaint-related, focusing on Resident #1 who was pushed by Resident #2 resulting in a fall and injury. The complaint included failure to notify the responsible party and failure to report the incident to the Department within 24 hours. The complaint was substantiated based on record reviews and staff interviews.
Findings
The facility failed to take appropriate actions during a sudden adverse change in Resident #1's condition, including failure to notify the responsible party. Additionally, the facility did not report a serious injury to the Department within 24 hours as required.
Deficiencies (2)
Failure to take appropriate actions to address Resident #1's sudden adverse change in condition, including failure to notify the responsible party.
Failure to report a serious injury to the Department within 24 hours following the occurrence.
Report Facts
Incident date: May 23, 2021
Incident report date: May 26, 2021
Department report date: May 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Reported incident to responsible party on 5/25/21 and provided details about notification failures | |
| Staff D | Witnessed incident and called 911; notified Staff B of incident | |
| AA | Interviewed regarding failure to notify responsible party and details of Resident #1's hospital transfer | |
| BB | Interviewed and stated he/she was never contacted by the facility regarding the incident |
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