Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Five Oaks Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy by not ensuring staff wore gowns and gloves during high-contact care for multiple residents with invasive devices and chronic wounds. An RN administered medications via a feeding tube to a resident on EBP using only gloves despite posted signage requiring a gown for high-contact device care. Two nurses and a NA transferred a resident with a PICC line using a mechanical lift while wearing only gloves, and no EBP signage had been posted for that resident. Another NA provided care to a resident with open sacral wounds, infections, and a central line while wearing gloves but no gown, despite clear EBP signage and available PPE. Staff interviews showed misunderstanding or reliance on missing signage, and leadership confirmed that gowns and gloves were required for these high-contact activities under the facility’s EBP policy.
Surveyors found expired medications and supplies in two medication rooms and one medication cart, including expired Jardiance tablets, Ocusoft eye cleanser wipes, and Promethegan suppositories. A nurse confirmed she was assigned to the affected cart and stated she checks it before each shift but had missed the expired item. Unit managers and night-shift nurses were reported to be responsible for routine checks of medication rooms, while the DON described a process in which unit managers check rooms and carts weekly and nurses check their carts prior to each shift, yet expired items remained in active storage.
A resident with cognitive impairments and a history of poor safety awareness fell from a transportation bus after being left unattended by staff. Despite instructions to remain seated, the resident unbuckled her seatbelt and attempted to exit the bus, resulting in a fall and multiple injuries. The incident occurred due to a lack of supervision and inappropriate footwear.
A resident at risk for pressure ulcers developed a significant wound due to the facility's failure to recognize and manage the condition effectively. Initial discoloration was noted, but there was a lack of detailed documentation and timely evaluation by a Wound Care Physician. The resident was not placed on a pressure-reducing mattress promptly, and there were inconsistencies in documenting wound care treatments. The wound deteriorated, requiring advanced treatments, and the absence of a Wound Care Provider during critical periods contributed to the deficiency.
A resident with severe cognitive impairment and an unstageable pressure ulcer experienced significant pain during wound debridement attempts over eight weeks. Despite visible signs of pain and verbal requests to stop, the facility failed to administer pain medication prior to procedures until late in the observation period. The care plan indicated a risk for pain, yet the resident did not receive scheduled or as-needed pain medication, nor were nonpharmacological interventions documented. Interviews with staff revealed a lack of awareness and action regarding the resident's pain management needs.
The facility failed to date and label insulin pens in four medication carts, leading to a deficiency. Undated Insulin Lispro, Insulin Glargine, and Insulin Aspart pens were found, despite instructions indicating they expire 28 days after first use. Staff interviews revealed a lack of awareness and adherence to dating protocols, with the DON confirming the responsibility lies with the nurse who opens the pens.
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) to two residents who remained in the facility after their Medicare Part A benefits ended. Although a Notice of Medicare Non-Coverage (NOMNC) was issued, the required ABN was not provided due to a lack of awareness among the Business Office Manager and Regional Business Office Manager.
A resident with obstructive uropathy had an indwelling urinary catheter placed, but the facility failed to update the care plan to include this. Despite observations confirming the catheter's presence, the care plan lacked necessary focus, goals, or interventions. The MDS Nurse acknowledged the oversight, and the DON confirmed the requirement for care planning, but the update was not completed within the required timeframe.
A resident with obstructive uropathy had a urinary catheter without a securement device, causing discomfort due to taut tubing. Despite orders to check the catheter placement every shift, observations revealed the absence of a securement device on multiple occasions. Nursing staff were unaware of the issue until it was highlighted, indicating a lapse in catheter care oversight.
The facility failed to follow infection control policies when a nurse aide did not wear a gown while assisting a resident on enhanced barrier precautions during toileting, and a wound care nurse did not change gloves and sanitize hands properly during wound care. The Infection Preventionist and Director of Nursing confirmed the need for adherence to PPE and hand hygiene protocols.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents with certain devices or chronic wounds. For a resident with a feeding tube, an RN administered medications via the feeding tube without wearing a gown, despite an EBP sign posted at the doorway and PPE available across the hall. The nurse used hand sanitizer and gloves but omitted the gown, later acknowledging awareness that the resident was on EBP and that the sign referenced gowns and gloves for high-contact care involving a feeding tube. The Infection Preventionist and Director of Nursing both stated that a gown and gloves should have been worn for this care. Another deficiency occurred with a resident who had a PICC line and was receiving IV antibiotics for endocarditis. During a transfer from wheelchair to bed using a mechanical lift, two nurses and a nurse aide entered the room and completed the transfer wearing only gloves and no gowns. They assisted the resident with rolling and removed the lift pad without donning gowns. There was no EBP signage posted inside or outside the resident’s room, even though the resident had a PICC line in place. One nurse reported she normally wore a gown and gloves for PICC-related care but was not prompted to don a gown for the transfer because there was no EBP sign. The Infection Preventionist later stated that the resident should have been placed on EBP due to the PICC line and that she had overlooked obtaining the order and posting the signage. A further deficiency was identified with a resident who had open wounds on the sacrum, infections, and a central line used for IV antibiotics. An NA entered this resident’s room, which had an EBP sign posted and PPE available outside the door, carrying only gloves and not wearing a gown. The NA provided care in the room, moved around the bed, accessed the closet, and exited the room still wearing gloves and carrying a trash bag, all without donning a gown. The NA stated she knew the resident was on EBP due to open wounds and infections but believed a gown was only required for dressing changes. The Infection Preventionist and DON stated that, due to the resident’s open wounds, infections, and central line, the NA should have worn both gown and gloves when providing high-contact care. Across these events, five staff members (three nurses and two nurse aides) did not follow the facility’s EBP policy, which defined high-contact activities as including dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, device care or use (including central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters), and wound care for chronic wounds or those with MDRO. The failures included not donning gowns during high-contact care for residents with a feeding tube, a PICC line, and chronic pressure ulcers with a central line, as well as the failure to identify and place a resident with a PICC line on EBP and post appropriate signage. The Administrator stated that he expected all staff members to use the appropriate PPE according to the enhanced barrier signs posted for each resident and to wear the required PPE when providing care to residents on EBP. However, the observations and interviews documented that staff either misinterpreted the EBP signage, relied solely on signage that was missing, or misunderstood when gowns were required, resulting in noncompliance with the facility’s infection control policy for EBP.
Expired Medications Found in Medication Rooms and Cart
Penalty
Summary
Surveyors identified a deficiency related to medication storage and control when expired medications were found in two of three medication rooms and one of seven medication carts reviewed. In the 300 hall medication room, a bottle of Jardiance 10 mg with an expiration date of 2/17/2026 was present; the nurse accompanying the surveyor confirmed the expiration date and stated that the unit manager was responsible for checking the medication room weekly for expired medications. The 300 hall Unit Manager, who had been employed at the facility for two months, reported she needed to confirm with the DON how often the medication room should be checked for expired medications. On Medication Cart #3, which was assigned to the same nurse, surveyors found a box of Ocusoft eye cleanser wipes with an expiration date of 10/2025; the nurse confirmed the expiration date and stated she checked her cart prior to each shift for expired medications and supplies but must have missed this item. In the 200 hall medication room refrigerator, surveyors found a box of Promethegan 12.5 mg suppositories with an expiration date of 1/2026; the nurse present confirmed the expiration date and stated that unit managers were responsible for weekly checks of medication rooms and that night shift nurses should check the medication room each night. The DON later stated that unit managers check medication expiration dates weekly in medication rooms and carts, nurses check their carts prior to each shift, and night shift nurses check for expired medications in medication rooms, and explained that medication expiration dates were checked because expired medications could lose effectiveness or become more potent over time.
Lack of Supervision Leads to Resident Fall from Transportation Bus
Penalty
Summary
The facility failed to provide necessary supervision to a cognitively impaired resident, leading to an avoidable accident. The resident, who had a history of poor safety awareness and was at moderate risk for falls, was left unattended on a transportation bus after returning from an outing. Despite being instructed to remain seated, the resident unbuckled her seatbelt and attempted to exit the bus without assistance. She was wearing slip-on shoes, which came off, causing her to lose her footing and fall down the bus steps onto the asphalt. The resident sustained multiple injuries from the fall, including a right shoulder bone dislocation, skin tears, abrasions, a tongue hematoma, a cracked tooth, and a head hematoma. She also experienced dizziness and vomiting, leading to a hospital assessment that revealed a left temporal subarachnoid hemorrhage, a right clavicle fracture, a right humeral fracture, and bilateral rib fractures. The incident occurred because no staff members remained on the bus to supervise the residents, despite the resident's known cognitive impairments and fall risk. Interviews with staff members involved in the outing revealed that the Activities Director, Activities Assistant, and Transportation Driver all exited the bus, leaving the residents unattended. The staff assumed the residents would remain seated, but the resident's impulsive behavior and lack of supervision led to the accident. The facility's failure to ensure adequate supervision and appropriate footwear for the resident directly contributed to the incident.
Removal Plan
- The affected resident, Resident #79, was immediately assessed by the onsite nurse practitioner prior to her being moved. Upon the initial assessment, it was deemed the resident was safe to be transported into the facility where she was placed in bed and continued to be assessed. Emergency Medical Services (EMS) was notified to transport the resident to the hospital for additional tests and exams. Resident #79 was readmitted to the facility.
- The Director of Nursing inquired if any other resident had fallen or had any other near miss on the van. No other residents were identified.
- The Interdisciplinary Team consisting of all department managers, Administrator and Director of Nursing met to review residents with outside appointments. They met to identify residents scheduled for transport using the medical record to identify residents that were unable to make their needs known, appropriately respond to direction, had a BIMS score less than 10, and those unable to comply with standard safety precautions. Identified residents will have increased supervision on their transport to and from the facility as well as proper footwear.
- Residents must have safe and appropriate footwear on at the time of the transfer. The Administrator, Director of Nursing, Social Services Director and Activities Director, inspected 100% of the residents to ensure all residents had appropriate footwear for any potential transport, whether scheduled or not. Only one resident did not have appropriate shoes for their given shoe size. The Director of Nursing purchased him a pair of lace up shoes for outings and medical appointments.
- The Director of Nursing will ensure adequate supervision is provided by determining the need of each resident being transported. This will be conveyed to the Van Driver to ensure compliance with the level of supervision required.
- All residents will be required to have appropriate footwear which, at the minimum, must have closed toes, a closed heel and non-skid soles. Slippers and other slide on footwear will be strictly prohibited in order to be transported by the facility van or approved vendor.
- Residents with confusion and poor safety awareness will require a staff person or trained volunteer to increase basic supervision during transport. The weekly transportation schedule will be reviewed in morning meeting prior to any transport and if a resident needs increased supervision, the Director of Nursing will ensure it is available at the time.
- Increased supervision will be assigned by the Transportation Coordinator after notification by the Director of Nursing. Those individuals assigned for increase supervision, will be trained verbally by the Administrator or Director of Nursing prior to service and will include how to encourage the resident to remain seated and fastened until the van driver can safely help them off the transport vehicle.
- Volunteers will be instructed on identifying unsafe situations-such as when a resident might unbuckle a seatbelt while the van is in motion, or when a resident is at risk of falling out of their seat-and will be trained to take appropriate measures to minimize potential negative outcomes such as encouraging the resident to remain seated and refastening the buckle, and alerting the driver.
- The Social Services Director or Director of Nursing will bring the transportation schedule to the morning meeting, Monday through Friday. The Director of Nursing and Social Service Director will ensure that any resident requiring increased supervision is properly identified and that necessary measures are in place.
- The Administrator informed the Staff Development Coordinator and Human Resources Specialist of the need to add training to orientation for all new hires regarding the need for residents to wear appropriate footwear. This will be covered as part of the general orientation for all departments.
- All activity staff, facility transportation driver, and contracted vendor that provides outside non-emergency transportation when the facility transportation is not available were educated by the facility Administrator and Director of Nursing that each resident must be dressed appropriately for any outing which includes safe (closed toe, closed/strapped heel, non-slip) footwear.
- Education was provided to all staff by nurse managers, department heads, and/or special assigned nurse on the need for each resident to be dressed appropriately for any outing which includes safe (closed toe, closed/strapped heel, non-slip) footwear. This in servicing was to be completed.
- The Van Driver was educated by the Director of Nursing that they were the ultimate stop gate to ensure everyone has safe footwear on prior to transfer. If a person does not have proper foot attire, they are to immediately notify the Director of Nursing or Administrator for further direction.
- To ensure on-going compliance, the van drivers will receive annual training on proper foot attire for all residents before the transportation is provided. This annual training will be completed by the Administrator and Maintenance Director.
- A letter was initiated by the facility Administrator to families notifying them of the facility's new requirement on safe (closed toe, closed/strapped heel, non-slip) footwear for residents to be transported.
Failure to Manage and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to adequately recognize and manage a developing pressure ulcer in a resident, leading to a significant deterioration of the wound. The resident, who was at risk for pressure ulcer development due to conditions such as diabetes, Parkinsonism, bladder incontinence, and decreased mobility, developed discoloration in the coccyx area. Despite the initial observation of discoloration on 11/20/2024, there was a lack of detailed documentation and measurement of the wound, and the resident was not evaluated by a Wound Care Physician until 12/6/2024, by which time the wound had become unstageable. The facility's inaction included failing to implement timely preventative measures and treatments as ordered. The resident was not placed on a pressure-reducing mattress until 12/7/2024, despite having a history of pressure ulcers. There were also inconsistencies in the documentation of wound care treatments, with several instances where treatments were not recorded as completed. The facility did not ensure continuous wound care provider evaluations, particularly when the Wound Care Physician was unavailable, leading to gaps in wound assessments and measurements. The resident's wound continued to deteriorate, requiring advanced treatments such as debridement and antibiotic therapy for infection. The facility's failure to consistently measure the wound and document care, along with the absence of a Wound Care Provider during critical periods, contributed to the worsening of the resident's condition. Interviews with staff revealed a lack of communication and coordination in managing the resident's wound care, further exacerbating the deficiency.
Inadequate Pain Management for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pain management for a resident with an unstageable pressure ulcer requiring wound debridement. Over a period of eight weeks, the resident experienced significant pain during attempted debridement procedures, which were repeatedly aborted due to the resident's discomfort. Despite the resident's visible signs of pain, such as crying and grimacing, and verbal requests to stop, the facility did not administer pain medication prior to these procedures until late in the observation period. The resident, who was admitted with diagnoses including diabetes and Parkinsonism, was noted to have severe cognitive impairment and required assistance with daily activities. The care plan indicated a risk for pain due to decreased mobility, yet the resident did not receive scheduled or as-needed pain medication, nor were nonpharmacological interventions for pain documented during the assessment period. The resident's pain was not adequately addressed, as evidenced by the lack of pain medication orders in the December 2024 and January 2025 Medication Administration Records (MAR). Interviews with facility staff, including wound care nurses and the Director of Nursing, revealed a lack of awareness and action regarding the resident's pain management needs. The Wound Care Physician acknowledged the resident's pain during debridement attempts but did not ensure effective pain control measures were in place. The facility's failure to anticipate and respond to the resident's pain needs, despite clear indications of discomfort, highlights a significant deficiency in the provision of safe and appropriate pain management services.
Failure to Date and Label Insulin Pens
Penalty
Summary
The facility failed to properly date and label insulin pens in four out of six medication carts, leading to a deficiency in medication management. Observations revealed undated insulin pens, including Insulin Lispro, Insulin Glargine, and Insulin Aspart, in medication carts #5, #1, #2, and #6. The manufacturer's instructions for these insulin types indicate they expire 28 days after first use, whether stored at room temperature or refrigerated. Interviews with staff, including unit managers and nurses, confirmed that the insulin pens should have been dated when removed from refrigeration, but this was not consistently done. Nurses were unaware of the undated pens in their carts, and some admitted to not noticing them during their shifts. The Consultant Pharmacist confirmed that the 28-day expiration period begins once the insulin pens are taken out of refrigeration. The Director of Nursing (DON) acknowledged that the responsibility for dating the insulin pens lies with the nurse who opens them, and that the nurse who retrieves insulin from stock should label it with the resident's name and date. The DON also stated that nurses on medication carts are responsible for checking medications for opened dates and labels. This lack of adherence to proper labeling and dating protocols for insulin pens resulted in a deficiency identified by surveyors.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) prior to the discharge from Medicare Part A skilled services for two residents. Resident #113 and Resident #302 were both issued a Notice of Medicare Non-Coverage (NOMNC) indicating the end of their Medicare Part A coverage for skilled services. However, neither resident nor their responsible parties received the required CMS-10055 ABN, which should have been provided when the residents remained in the facility after their Medicare benefits ended. Interviews with the Business Office Manager (BOM) and the Regional Business Office Manager revealed a lack of awareness regarding the requirement to issue the CMS-10055 ABN in addition to the NOMNC. The BOM, who had been trained by the Regional Business Office Manager, confirmed that she was only instructed to issue the NOMNC and was unaware of the necessity for the ABN. The Administrator also acknowledged that both the NOMNC and ABN should be issued when a resident's Medicare Part A benefits are ending, and they continue to stay in the facility.
Failure to Update Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to update the care plan for a resident who had an indwelling urinary catheter placed. The resident, who was admitted with a diagnosis of obstructive uropathy, received a physician's order for the catheter on February 4, 2025. Despite this, the care plan dated February 22, 2025, did not include any focus, goal, or interventions related to the catheter. Observations on February 24, 2025, confirmed the presence of the catheter, yet the care plan remained unupdated. Interviews with the MDS Nurse and the Director of Nursing revealed that the responsibility for updating the care plan lay with the MDS Nurse, who acknowledged the oversight. The DON confirmed that urinary catheters should be care planned and expressed uncertainty as to why the update had not occurred. The care plan should have been revised within 14 days of the catheter placement, but this was not done, leading to the deficiency.
Failure to Secure Urinary Catheter Tubing
Penalty
Summary
The facility failed to secure a urinary catheter tubing to prevent tension and/or trauma for a resident diagnosed with obstructive uropathy. The resident was admitted with a physician's order for a urinary catheter, which required the placement of the privacy bag and leg strap to be checked every shift. However, the care plan did not include any focus, goal, or interventions related to urinary catheters. Observations on two consecutive days revealed that the resident's catheter tubing was pulled taut, and there was no securement or stabilizing device in place, causing discomfort to the resident. Interviews with the nursing staff indicated a lack of awareness and oversight regarding the securement of the catheter. Nurse #1 admitted to not noticing the absence of a securement device on the specified dates and only addressed the issue after it was brought to attention. The Director of Nursing was also unaware of the deficiency and suggested that the resident might have removed the securement device. This oversight in catheter care led to the deficiency being identified during the survey.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures, resulting in deficiencies in the use of personal protective equipment (PPE) and hand hygiene practices. Nurse Aide #1 did not wear the required gown while assisting Resident #140, who was on enhanced barrier precautions (EBP) due to a wound, during toileting. Despite a sign indicating the resident's EBP status, the aide only wore a mask and gloves, failing to notice the sign and the need for a gown. Interviews with the Infection Preventionist and Director of Nursing confirmed that the aide should have worn a gown during this high-contact activity. In another incident, Wound Care Nurse #2 did not follow proper hand hygiene protocols while caring for Resident #48, who required wound care. After cleaning the resident's sacral wound, the nurse failed to doff her gloves, sanitize her hands, and don new gloves before applying skin prep to the wound border. The nurse admitted to forgetting this step due to nervousness during observation. The Infection Preventionist and Director of Nursing both stated that the nurse should have followed the hand hygiene policy, which requires changing gloves and sanitizing hands when transitioning from a dirty to a clean procedure. The facility's policies on EBP and hand hygiene were not followed by the staff members involved, leading to these deficiencies. The Infection Preventionist and Director of Nursing expressed their expectations for staff to adhere to these guidelines to prevent the spread of infections. The Administrator also emphasized the importance of following the established procedures during resident care activities.
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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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Nursing homes near Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Greens At Cabarrus | 1.1 mi | ★★★★★ | 2 | 0 |
| Copperfield Health & Rehabilitation | 1.2 mi | ★★★★★ | 8 | 0 |
| Kannapolis Health And Rehabilitation | 1.7 mi | ★★★★★ | 11 | 1 |
| Cabarrus Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 2 | 0 |
| The Gardens Of Taylor Glen Retirement Community | 2.8 mi | ★★★★★ | 1 | 0 |
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