Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Presidential Oaks during CMS and state inspections, most recent first.
EBP was not implemented for two residents with pressure ulcers, as there was no EBP signage, PPE setup, or care plan indication for high-contact care activities. During a wound dressing change, an LPN changed gloves but did not perform hand hygiene after glove removal. The facility also could not show evidence of legionella-related water management actions, and several infection prevention policies had not been reviewed annually.
Failure to monitor antibiotic use and McGeer criteria. The facility did not document infection symptoms or antibiotic appropriateness for several residents receiving antibiotics for UTI, and an IP confirmed no McGeer assessment was completed for those cases. The antibiotic line list also lacked required details, and there was no tracking or QAPI discussion of antibiotics used outside the criteria or for prophylaxis.
Resident Council Meeting Access and Grievance Response Deficiency: The facility failed to provide a private space for resident group meetings, notify residents about upcoming meetings, and document timely responses to resident grievances. During a resident group meeting, several residents said they were unaware of the council meetings or had never been invited, and one resident did not know LTC residents could elect their own President. Meeting minutes showed LTC residents raised concerns about activities, nursing care, food, and missing items, but Staff D confirmed there was no response to those concerns.
Failure to notify the provider of repeated med refusals: A resident with paroxysmal AFib and atherosclerotic heart disease refused several ordered meds, including aspirin, isosorbide dinitrate, losartan, and verapamil, over multiple days. The DON confirmed there was no documentation that the provider was notified before the resident later had severe chest pain and agreed to go to the hospital for further evaluation.
A resident reported feeling rushed during incontinence care and said staff were sometimes not nice, but the concern was not turned into a grievance and no investigation was completed. Facility policy required staff to generate and route grievance forms whenever concerns were heard or observed, yet an LPN’s discussion with the resident did not lead to grievance processing by the Social Services department or administration.
A resident sustained a spiral fracture of the left tibia, and the facility did not conduct a thorough investigation as required by its policy. The DON did not interview LNAs who had cared for the resident prior to the injury, and key staff were not asked to provide statements, resulting in the cause of the injury remaining unidentified.
A resident assessed as dependent for transfers and requiring a mechanical lift was repeatedly transferred by staff using unsafe manual techniques, despite clear recommendations from PT and an updated care plan. The resident expressed pain during these transfers and was later found to have a spiral fracture of the lower leg.
The facility failed to store food properly, as observed in the kitchen. An open, undated bag of frozen rib patties was found in the walk-in freezer, and a box of tomatoes with black spots and moldy pepper jack cheese were found in the refrigerator. These issues were confirmed by the Chef Manager and Assistant Chef Manager, violating the FDA 2022 Food Code requirements for food storage.
The facility failed to provide written notice of transfer or discharge for four residents who were hospitalized. A resident was transferred to the hospital without documentation of a notice of transfer, and staff admitted that no notice was provided due to the short duration of the hospital stay. Another resident was transferred without a written notice, and staff confirmed that notices are only faxed to the LTC Ombudsman. Additionally, a resident with a power of attorney for healthcare was sent to the hospital multiple times without receiving a written notice of transfer discharge.
The facility failed to notify residents or their representatives of the bed hold policy before hospital transfers. Four residents were transferred without receiving the required notification, as confirmed by staff interviews and record reviews. The facility's policy mandates that social workers or designees discuss bed hold options, but this was not adhered to.
Failure to Implement EBP, Hand Hygiene, and Infection Prevention Controls
Penalty
Summary
Enhanced Barrier Precautions were not implemented for two residents with pressure ulcers. Resident #30 had a stage II pressure ulcer to the left heel and a stage II pressure ulcer to the sacrum, but physician orders did not indicate EBP was in place, and observation of the room showed no signage indicating EBP usage. Resident #55 had a daily dressing change ordered for a stage 2 pressure injury, but observation of the room showed no EBP sign and no PPE cart available, and the care plan did not indicate enhanced barrier precautions for high-contact care activities. Facility staff, including the Unit Manager, DON, and Infection Preventionist, confirmed that both residents should have been on EBP for their pressure ulcers. During a dressing change for Resident #55, the LPN changed gloves between dirty and clean tasks but did not perform hand hygiene after removing gloves and before putting on new gloves to continue wound care. Facility policy required hand washing after removing gloves and allowed alcohol-based solution unless hands were visibly soiled. The report also noted that the facility could not provide evidence that water management interventions for legionella prevention were being performed, and the Infection Preventionist confirmed infection prevention policies such as Antibiotic Stewardship Program, Infection Surveillance, and Antibiotic Use Assessment and Documentation had not been reviewed annually.
Failure to Monitor Antibiotic Use and McGeer Criteria
Penalty
Summary
The facility failed to implement a system to monitor antibiotic use for 3 of 5 residents reviewed, identified as residents #11, #57, and #7. Facility policy titled Antibiotic Stewardship Program stated the center would follow McGeer criteria to identify infections and that nursing partners would participate in the QAPI program to support approved antibiotic-use guidelines. However, review of the facility antibiotic line lists for November 2025, December 2025, and January 2026 showed missing infection symptoms and no documentation that the antibiotics were appropriate or met McGeer criteria. For resident #11, an order for ertapenem 500 mg IV daily for 7 days was documented for a UTI, with symptoms listed as GI complaints and pain, and the Infection Preventionist confirmed no McGeer assessment or antibiotic appropriateness review was completed. For resident #57, an order for Augmentin 875 mg-125 mg PO every 12 hours for 7 days was listed for a UTI, but symptoms were not noted, and no McGeer assessment or appropriateness review was completed. For resident #7, an order for nitrofurantoin 50 mg PO daily was listed for a UTI with altered mental status, fatigue, and malaise, but the McGeer worksheet was blank, and the Infection Preventionist confirmed no assessment of McGeer criteria or antibiotic appropriateness was completed. The Infection Preventionist also stated antibiotic treatments not fitting McGeer criteria were not being tracked and there was no reporting or discussion in QAPI regarding infections treated outside the criteria or prophylactic treatment.
Resident Council Meeting Access and Grievance Response Deficiency
Penalty
Summary
The facility failed to ensure residents were provided a private space for a resident group to meet on a regular basis, were made aware of upcoming meetings, and had resident and group grievances addressed promptly with documented responses and rationale. During interview and observation, five residents attending the resident group meeting stated they were not aware of a Resident Council meeting. One resident said he/she did not know residents could elect a President for the SN and LTC council and believed the President represented the entire building. Another resident reported being admitted in October 2025 and never being told about a monthly meeting to discuss issues in the facility, and stated he/she would have attended. A third resident stated he/she had not been asked to attend a group meeting until that day and wanted to attend in the future. Review of Resident Council meeting minutes showed LTC residents raised concerns about activities, nursing care, food, and missing items, but Staff D confirmed there was no response to the LTC residents’ concerns. The facility policy stated activity and nursing staff were responsible for inviting and encouraging appropriate residents to attend, documenting unresolved issues on a Department Response Form within 48 hours, returning completed forms within 10 days, and bringing issues up at the following meeting as resolved. The report also noted the Resident Council president was not a long-term resident and was from the independent living side of the organization, while the resident group included long-term care and other facility residents.
Failure to Notify Provider of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the physician when Resident #71 refused multiple ordered medications. Review of the January 2026 MAR showed physician orders for aspirin 81 mg at bedtime for paroxysmal atrial fibrillation, isosorbide dinitrate 5 mg two tablets at bedtime for atherosclerotic heart disease of the native coronary artery without angina pectoris, losartan potassium 50 mg daily for atherosclerotic heart disease of the native coronary artery without angina pectoris, and verapamil HCl ER 120 mg twice daily for atherosclerotic heart disease of the native coronary artery without angina pectoris. The MAR documented refusals of aspirin on 1/1/26 through 1/4/26, isosorbide dinitrate on 1/1/26 through 1/4/26, losartan on 1/3/26 and 1/4/26, and verapamil on 1/1/26 and 1/2/26 at 8:00 p.m. and on 1/3/26 and 1/4/26 at 9:00 a.m. and 8:00 p.m. During interview, the DON confirmed there was no documentation that the provider was notified of the refused medications prior to 1/5/26. A provider note dated 1/5/26 stated that Resident #71 had been refusing hypertensive medication and had severe chest pain, and the resident agreed to go to the hospital for further evaluation.
Failure to Generate and Investigate Resident Grievance
Penalty
Summary
The facility failed to follow its grievance policy for generating, investigating, and resolving grievances for one resident reviewed for abuse concerns. The facility policy stated that staff receiving a concern must generate a grievance form, complete the required information, deliver it to the Director of Social Services, and have the grievance logged and assigned for investigation and action. The policy also stated that residents, family members, or responsible parties do not need to formally ask for a grievance to be filed, and staff learning of or hearing the concern should generate the form. Resident #46 stated during interview that staff were busy and rushed during incontinence care and that the resident had recently told a staff member about these concerns, but nothing was done. A progress note documented that an LPN spoke with Resident #46 about an LNA on duty and that the resident felt rushed and sometimes staff were not nice. The Administrator in Training stated that Resident #46's concerns did not generate a grievance and no investigation was done.
Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged violation involving a resident who sustained a spiral fracture of the left tibia. Nursing progress notes indicated that the resident was found with pain, swelling, and redness in the left lower extremity, which was later diagnosed as a minimally displaced spiral oblique fracture. The injury was considered of unknown source, as the cause could not be explained by the resident and was not observed by staff. Despite the seriousness of the injury, the facility did not follow its own policy requiring a comprehensive investigation of such incidents. Interviews revealed that the Director of Nursing did not interview any Licensed Nursing Assistants (LNAs) who had cared for the resident on the days leading up to the discovery of the injury. One LNA reported that the resident had expressed pain during a transfer and had been kept in bed due to leg pain, but was not interviewed or asked to provide a statement regarding the injury. The facility's policy mandates that all nursing department witnesses and suspects be interviewed and their statements recorded, but this was not done, and the cause of the fracture was not identified.
Failure to Implement Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to implement appropriate transfer interventions for a resident who was assessed as requiring a mechanical lift (hoyer) with two staff for transfers. Despite repeated recommendations and notifications from physical therapy staff, including documentation on multiple occasions that the resident was dependent for transfers and unable to bear weight through the lower extremities, nursing staff continued to use unsafe transfer techniques such as a one-person stand-pivot and bear hugging. These methods were explicitly identified as unsafe for both the resident and staff, and the need for a mechanical lift was communicated verbally and in writing to nursing staff and the unit manager. On one occasion, a licensed nursing assistant transferred the resident using a stand-pivot technique, during which the resident expressed pain. The following day, the resident was kept in bed due to complaints of pain and was observed holding their left leg. Subsequent nursing assessment revealed swelling, redness, and tenderness in the left lower extremity, and an x-ray confirmed a minimally displaced spiral fracture of the mid to distal tibia. The resident's care plan had been updated to require a two-person hoyer transfer, but this intervention was not followed, resulting in injury.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage in accordance with professional standards for food service safety. During an observation in the kitchen, surveyors found an open and undated bag of frozen rib patties in the walk-in freezer. Additionally, in the walk-in refrigerator, a box of tomatoes with visible black spots and a bag of cubed moldy pepper jack cheese were discovered. These findings were confirmed through an interview with the Chef Manager and Assistant Chef Manager. The review of the FDA 2022 Food Code highlighted the requirement for food to be stored in packages, covered containers, or wrappings to prevent contamination, and to be kept in a clean, dry location away from potential contaminants.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide written notice of transfer or discharge for four residents who were hospitalized. Resident #48 was transferred to the hospital on 10/27/24, but no documentation of a notice of transfer was found in the medical record. Staff E from Social Services admitted that no notice was provided because the hospital stay was less than 24 hours. Similarly, Resident #6 was transferred to the hospital on 10/20/24, and there was no written notice of transfer and discharge in the medical record. Staff A, a social worker, confirmed that the facility only faxes notices to the Office of Long Term Care Ombudsman and does not provide them to the resident or their representative. Resident #64 was transferred to the hospital on 9/10/24 for a scheduled procedure, but no written notice of transfer and discharge was documented. Staff A confirmed that the facility does not provide such notices to residents or their representatives. Additionally, Resident #16, who had an activated power of attorney for healthcare, was sent to the hospital on multiple occasions without receiving a written notice of transfer discharge. Staff A confirmed that the facility does not provide written notices of transfer discharge to residents or their representatives.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed hold policy prior to transferring them to a hospital, as required. This deficiency was identified during a review of the medical records of four residents who had been hospitalized. For Resident #48, there was no evidence in the medical record that the bed hold policy was communicated upon their discharge to the hospital. Staff E from Social Services confirmed this oversight during an interview. Similarly, Resident #16's records showed multiple hospital transfers without any documentation of bed hold policy notification, which was corroborated by Staff A from Social Services, who admitted that such notifications were not being made. Resident #6 was transferred to the hospital after an incident where they were found on the floor, yet there was no documentation of a bed hold notice being provided. Staff H from the Business Office and Staff D, the Administrator, confirmed that bed hold notices were not routinely provided at each transfer. Additionally, Resident #64 was transferred for a scheduled procedure without any record of a bed hold notice being given. The facility's policy, as reviewed, stated that the social worker or designee should contact the resident or representative to discuss bed hold options, but this was not followed in these cases.
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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) |
|---|---|---|---|---|
| Pleasant View Center | 0.4 mi | — | 9 | 0 |
| Harris Hill Center, Genesis Healthcare | 1.2 mi | ★★★★★ | 11 | 0 |
| Havenwood-heritage Heights | 2.5 mi | ★★★★★ | 6 | 0 |
| Epsom Healthcare Center | 10 mi | ★★★★★ | 11 | 0 |
| Hackett Hill Healthcare Center | 11.6 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.