Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 The Oaks during CMS and state inspections, most recent first.
Dietary staff did not monitor or document the chemical sanitization level of the low temperature dish machine, resulting in the machine operating below the required chlorine level. The dietary manager and aides were unaware of the need to test the sanitizer level, and the issue was only discovered after a malfunction was observed and repaired. This failure could have affected all residents receiving food service.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Debris including straws, cup lids, empty chip bags, and milk cartons was found behind all dumpsters, with staff interviews revealing confusion over which department was responsible for cleaning the area. The lack of clear assignment led to debris being left behind after garbage collection.
The facility submitted inaccurate RN staffing data to CMS because agency RNs did not consistently clock in, leading to missing hours in the PBJ report. Although daily schedules showed an RN was present, the lack of proper timecard documentation resulted in incomplete reporting of RN coverage.
The facility closed its dining room for nine days after a single staff member tested positive for COVID-19, restricting several cognitively intact residents who preferred to eat in the dining room. Despite the facility's policy lacking clear outbreak definitions or dining instructions, and public health officials confirming that group dining should not have been suspended for one case, the dining room remained closed, leading to resident dissatisfaction and a failure to support resident choice.
Resident council meetings were consistently held in open, non-private areas such as the dining room and adjacent lounge, resulting in frequent disruptions and lack of privacy due to staff and visitor traffic. Residents expressed frustration over the inability to meet privately, and facility leadership was unaware of the requirement for a private meeting space.
Two residents admitted with complex medical needs did not have baseline care plans developed within 48 hours of admission. Although admission assessments were completed, staff reported that baseline care plans were typically finalized within 72 hours, resulting in a delay in formally addressing the residents' immediate care needs.
A resident with lymphedema and other chronic conditions did not receive physician-ordered compression wraps to both legs as documented in the TAR. The resident was found without the wraps during an observation, despite staff documentation indicating they had been applied. The nurse whose initials appeared on the record denied performing the task and was unaware of the proper procedure, resulting in a failure to meet professional standards of care.
A resident did not receive the specialized rehabilitative services required for their care, as the facility failed to provide or arrange for these necessary interventions according to the resident's care plan.
Two residents who shared rooms did not have privacy curtains, resulting in a lack of privacy when needed. Both residents, who were cognitively intact, reported the absence of curtains for an extended period and had requested them without resolution. Facility staff, including housekeeping and the Administrator, were unaware of the missing curtains despite daily checks being expected.
A resident with lymphedema had a physician's order for daily compression wraps, but nursing documentation falsely indicated the wraps were applied when they were not. Observation confirmed the wraps were not present, and the nurse whose initials appeared on the record stated she did not perform the task or know how her initials were entered. Facility leadership confirmed that documentation should accurately reflect care provided.
The facility failed to address grievances raised during Resident Council Meetings over several months, concerning untimely water cup refills and unavailable snacks. Despite documentation of these issues, no follow-up actions were demonstrated. Interviews with two cognitively intact residents confirmed the ongoing nature of these unresolved grievances. The Activities Director outlined the grievance reporting process, but the DON admitted to not addressing the concerns, and the Administrator acknowledged the lack of follow-up.
A resident in a LTC facility did not receive requested dentures due to a lapse in transitioning dental care services. The resident, who was cognitively impaired and on a mechanically altered diet, had requested new dentures, which were approved by Medicaid. However, the facility terminated their contract with the dental provider before the dentures could be made. The social worker failed to contact the resident or their responsible party to transition to a new dental provider, resulting in the resident not receiving the necessary dental care.
A resident, who was cognitively intact, was not invited to participate in care plan meetings since August 2022, despite expressing a desire to be included. The facility's social worker and office manager confirmed the oversight, with the latter assuming the resident preferred to consult with a friend. The administrator acknowledged that residents should be invited to their care plan meetings.
A resident with urinary bladder cancer and a urostomy had their tubing unsecured, contrary to the physician's order. The care plan required the tubing to be anchored with a leg band, but during care, it was observed unsecured. Staff interviews revealed a lack of awareness and responsibility for securing the tubing, with both a nurse aide and a nurse failing to ensure the tubing was properly anchored.
A resident with Vascular Dementia and Hemiparesis fell during incontinent care when a nurse aide attempted to reposition her alone, contrary to her care plan requiring two-person assistance. The bed was in a high position, contributing to the fall, which resulted in a hematoma on the resident's forehead. Medical evaluations showed no fractures or intracranial hemorrhage.
Failure to Monitor Chemical Sanitization in Dish Machine
Penalty
Summary
Dietary staff failed to demonstrate competency in monitoring the chemical sanitization level of the low temperature dish machine, as required by facility policy and manufacturer guidelines. The dish machine was observed to have a chlorine level of 0 ppm, below the minimum requirement of 50 ppm. The dietary manager confirmed that staff were only recording rinse/wash temperatures and not the chemical sanitization level. Interviews revealed that neither the dietary manager nor dietary aides had previously measured or documented the chemical sanitization level for the dish machine, and the dietary manager was unaware of the minimum required level. Further review showed that the dish machine had a malfunctioning nozzle, which was only identified and repaired after the deficiency was observed. Staff interviews indicated a lack of training and awareness regarding the need to test and document the chemical sanitization level each shift. The failure to monitor and document the chemical sanitization process could have affected all 111 residents served by the dietary department.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Improper Disposal of Garbage and Refuse Behind Dumpsters
Penalty
Summary
Debris such as straws, cup lids, empty chip bags, and empty milk cartons was observed behind all three dumpsters during an inspection. Staff interviews revealed confusion regarding responsibility for cleaning the dumpster area, with the Maintenance Director, Dietary Manager, and Administrator each providing differing accounts of which department was assigned to this task. The Maintenance Director stated he typically picked up debris in the parking lot but believed the dietary department was responsible for the dumpster area, while the Dietary Manager indicated that maintenance was responsible. The Administrator clarified that the dietary department was responsible, but maintenance and housekeeping were currently handling the area. The debris was left behind the dumpsters after garbage collection, and there was no clear assignment or consistent practice for ensuring the area was cleaned daily.
Inaccurate RN Staffing Data Submitted Due to Agency Nurses Not Clocking In
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system for one of three reviewed quarters, specifically regarding Registered Nurse (RN) hours. The PBJ report for the specified quarter showed no RN hours recorded on four dates, while daily staff schedules indicated that an RN was onsite for at least eight hours on those days. Nursing staff time detail reports, however, did not reflect the presence of an RN, aligning with the PBJ data. Interviews with the Scheduling Coordinator revealed that agency RNs sometimes did not clock in upon arrival, resulting in their hours not being captured in the facility's timecard system or the PBJ submission. The Administrator confirmed unawareness of this issue and acknowledged that all staff, including agency nurses, are required to document their time in the system.
Failure to Honor Resident Dining Preferences During COVID-19 Response
Penalty
Summary
The facility failed to honor residents' preferences for dining location by closing the dining room for nine days following a single employee testing positive for COVID-19. This action affected at least three cognitively intact residents who regularly ate in the dining room and expressed unhappiness and distress over the closure. The facility's COVID-19 Response Program policy, last revised in August 2025, did not define 'outbreak' or provide instructions regarding dining activities during an outbreak, only requiring notification of the health department for suspected or confirmed cases. Despite this, the Administrator and DON reported that they closed the dining room based on what they believed were instructions from the county health department, although no documentation or confirmation of such guidance was found. Interviews with county health officials revealed that an outbreak is defined as two or more cases within a 14-day period, and that the facility was only under surveillance with one positive case, not requiring cessation of group dining. The Communicable Disease Nurse and Public Health Nursing Supervisor both stated that they would not have advised the facility to suspend group dining with only one positive case. The facility's actions were not supported by their own policy or by public health guidance, resulting in the residents' right to choice and self-determination being restricted without appropriate justification.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to honor residents' rights to organize and participate in resident council meetings in a private setting. Over a six-month period, all resident council meetings were held in the dining area or a lounge adjacent to the dining room, both of which lacked privacy due to being open spaces without walls or doors. Residents reported frequent disruptions from staff and visitors, as the lounge was directly next to the entrance hallway and dining room, allowing conversations to be overheard and meetings to be interrupted. Resident council members expressed frustration about the lack of privacy and the inability to conduct meetings without interference. The activity director confirmed that there was no dedicated activity room or private area available for these meetings and acknowledged that disruptions occurred when staff and visitors were unaware of the meetings. The administrator was unaware of the requirement for private meeting spaces and had not received complaints from residents regarding this issue.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans addressing the immediate needs of two residents within 48 hours of their admission. One resident was admitted with diagnoses including diabetes, heart failure, and end stage chronic kidney disease, and required dialysis, antidepressant, and diuretic medications. Despite the completion of the nursing admission assessment, there was no evidence that a baseline care plan was developed within the required timeframe. Staff interviews revealed that baseline care plans were typically completed within 72 hours, often during the interdisciplinary care conference, and sometimes delayed over weekends. Another resident was admitted with multiple sclerosis, polyneuropathy, depression, and pressure ulcers, requiring antidepressant medications, physical therapy, and daily wound care. Similarly, the nursing admission assessment was completed, but no baseline care plan was documented within 48 hours of admission. Staff interviews confirmed that the practice was to complete baseline care plans within 72 hours, not the required 48 hours, and that immediate care needs were not formally addressed in a timely manner for these residents.
Failure to Apply Compression Wraps as Ordered and Inaccurate Documentation
Penalty
Summary
A deficiency occurred when nursing staff failed to apply compression wraps to a resident's legs as ordered by the physician for the management of lymphedema. The resident, who had diagnoses including congestive heart failure, morbid obesity, and lymphedema, had a physician's order for bilateral leg compression wraps to be applied every morning and removed every evening. On the day in question, the Treatment Administration Record (TAR) indicated that the wraps were applied at 8:00 AM by a nurse. However, during an interview and observation at 10:00 AM, the resident was found without compression wraps and expressed concern about the omission, stating that staff had previously applied and removed the wraps as ordered. Further investigation revealed that the nurse whose initials appeared on the TAR for the application of the wraps denied applying them and was unsure how her initials were recorded. She also lacked knowledge about the frequency and timing of the wrap application and removal. The Director of Nursing confirmed that physician-ordered tasks should be carried out by nursing staff. The failure to apply the compression wraps as ordered and the inaccurate documentation on the TAR constituted a failure to meet professional standards of quality care.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which were necessary to meet the resident's assessed needs. This inaction resulted in the resident not receiving the appropriate rehabilitative interventions as indicated in their care plan.
Failure to Provide Privacy Curtains for Shared Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains for two residents who shared rooms, resulting in a lack of privacy when needed. Both residents were cognitively intact and reported not having privacy curtains for an extended period. Observations confirmed that neither resident had a privacy curtain in place, and their beds were positioned closest to the door, offering no privacy when the door was open. One resident stated he had not had a privacy curtain in a while and could not recall the reason, while the other reported never having a privacy curtain since admission and had requested one from staff without success. Interviews with facility staff revealed that the Director of Housekeeping was unaware of the missing curtains and stated that housekeeping was responsible for checking and maintaining privacy curtains daily. The Administrator also was not aware of the missing curtains and confirmed that it was housekeeping's responsibility to ensure each resident had a privacy curtain and that they were clean and in place. Daily checks for privacy curtains and their cleanliness were expected but not carried out effectively, leading to the deficiency.
Inaccurate Documentation of Compression Wrap Application
Penalty
Summary
The facility failed to ensure accurate and truthful documentation regarding the application of compression wraps for a resident with a physician's order for daily application and removal of the wraps to both legs for lymphedema. Review of the Treatment Administration Record (TAR) showed that nursing staff documented the application of compression wraps at 8:00 AM. However, during an interview and observation at 10:00 AM, the resident stated she did not have compression wraps on, and it was confirmed by direct observation that no wraps were present on either leg. Further investigation revealed that the nurse whose initials appeared on the TAR as having applied the wraps at 8:00 AM stated she did not actually perform the task and was unaware of how her initials were recorded for that time. The nurse also indicated she did not know the frequency or timing for the application or removal of the wraps. Both the DON and the Administrator confirmed that the expectation is for staff to accurately document only the tasks they have personally completed, and that initials on the TAR should reflect the individual who performed the task.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances raised during Resident Council Meetings over a three-month period. Concerns were consistently noted in the meeting minutes for February, March, and April 2024, regarding the untimely filling of water cups and the unavailability of snacks for residents. Despite these issues being documented, the facility did not demonstrate any response or follow-up actions to resolve the grievances. The Resident Council Follow-Up forms attached to the meeting minutes did not show any facility response to the concerns raised. Interviews with residents and staff further highlighted the lack of action taken by the facility. Two residents, both cognitively intact, confirmed during a July 2024 meeting that the issues had been ongoing and unresolved. The Activities Director explained the process of reporting grievances to the appropriate department heads, but the Director of Nursing admitted to not addressing the concerns. The Administrator also acknowledged that grievances should have been addressed and followed up with the residents, indicating a breakdown in the facility's grievance resolution process.
Failure to Provide Dentures to Resident
Penalty
Summary
The facility failed to assist a resident in obtaining dentures, which was necessary for their dietary needs and overall well-being. The resident, who was cognitively impaired and had a diagnosis of hemiplegia, was admitted with a mechanically altered diet due to weight fluctuations secondary to hemodialysis. The resident had previously requested new dentures from the facility dentist, as noted in the dental provider's documentation, but had not received them. The upper dentures had been approved by Medicaid, but the facility terminated their contract with the dental provider before the dentures could be made. The transition to a new dental provider was not effectively managed, as the facility's social worker did not reach out to the resident or their responsible party to offer dental services. Despite receiving new consent forms from the new dental provider, the social worker admitted to not contacting the resident due to being busy. Consequently, the resident's request for dentures was not fulfilled, and the responsible party was not informed about the status of the dentures. The facility administrator acknowledged that dental services should be provided in a timely manner, indicating a lapse in the facility's process for transitioning dental care services.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to invite a resident to participate in the care planning process, which is a requirement for person-centered care. The resident, who was cognitively intact, expressed during an interview that he had not been invited to attend a care plan meeting for a long time and desired to be included. The facility's social worker confirmed that the resident had not attended a care plan meeting since August 2022 and could not verify if he had been invited to any meetings after that date. The office manager admitted to not inviting the resident to his care plan meetings, assuming he preferred to consult with a friend, and acknowledged the oversight in not sending invitations to both the resident and his friend. The facility administrator confirmed that residents should be invited to their care plan meetings.
Failure to Secure Urostomy Tubing
Penalty
Summary
The facility failed to secure the urostomy tubing for a resident as per the physician's order. The resident, who was admitted with urinary bladder cancer and urine retention, required extensive assistance with activities of daily living and had a urostomy. The care plan specified that the catheter tubing should be anchored using a leg band to prevent excess tension. However, during an observation of incontinent care, the urostomy tubing was found unsecured, and no anchoring device was present on the resident's legs. Interviews with the staff revealed a lack of awareness and responsibility regarding the securing of the urostomy tubing. The nurse aide was unaware of the unsecured tubing at the start of her shift and believed it was the nurses' responsibility to apply the anchors. Similarly, the nurse on duty did not check the tubing status at the beginning of her shift and was unaware of the absence of the stabilization device. The Director of Nursing confirmed that it was expected for the nursing staff to secure the urinary catheter tubing to prevent injury and maintain urine flow.
Failure to Provide Safe Incontinent Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide incontinent care in a safe manner, resulting in a fall for Resident #29. Resident #29, who was admitted with diagnoses of Vascular Dementia and Hemiparesis affecting the right side of her body, required two-person assistance for bed mobility. During an incident, a nurse aide attempted to reposition Resident #29 alone, which led to the resident rolling off the bed and falling to the floor. At the time of the fall, the bed was in a high position, which contributed to the severity of the incident. The incident report indicated that during morning care, Resident #29 was turned onto her left side by a single nurse aide, who then attempted to adjust the under pad. This action caused the resident to roll off the bed. The fall resulted in a hematoma on the resident's left forehead, although subsequent medical evaluations, including a CT scan and x-rays, showed no fractures or intracranial hemorrhage. The resident was returned to the facility the same day after being sent out for evaluation. Interviews with staff revealed that the nurse aide involved in the incident did not seek assistance from another staff member, despite being available. The nurse practitioner and another nurse assessed the resident immediately after the fall. The facility's care plan for Resident #29 clearly indicated the need for two-person assistance for bed mobility, which was not followed during the incident, leading to the deficiency.
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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 Winston-salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silas Creek Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Homestead Hills | 1.5 mi | ★★★★★ | 0 | 0 |
| Willow Valley Center For Nursing And Rehabilitatio | 1.7 mi | ★★★★★ | 10 | 1 |
| Arbor Acres United Methodist Retirement Community | 2.2 mi | ★★★★★ | 2 | 0 |
| Brookridge Retirement Community | 4.6 mi | ★★★★★ | 1 | 0 |
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