Four Oaks Health Care Center

In the surveyor’s words

From the most serious findings on record at Four Oaks Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Aug 26, 2021

  Based on review of facility policy, medical record review, review of Emergency Medical Services (EMS) documentation, and interview, the facility failed to ensure a completed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to ensure a completed POST form was in the medical record and available to staff placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #1 was found unresponsive and facility staff initiated Cardiopulmonary Resuscitation (CPR) and lifesaving interventions against the resident's and the resident's representative's wishes. […]

• Immediate jeopardy, isolatedF842Aug 26, 2021

  Based on review of facility policy, review of medical records, review of Emergency Medical Services (EMS) documentation, and interview, the facility failed to ensure a medical record was complete and accurate for 1 resident (Resident #1) of 6 residents reviewed for advance directive status. Resident #1's medical record did not include a completed Physicians Order for Scope of Treatment (POST) form indicating the resident's end of life wishes, resulting in facility staff initiating Cardiopulmonary Resuscitation (CPR) and lifesaving interventions against the resident's and the resident's representative's wishes, and placing Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to… […]

• No harm, potential for more than minimal, patternF880Feb 23, 2023

  Based on facility policy review, medical record review, observation, and interview the facility failed to maintain infection control for 2 residents (Resident #33 and Resident #41) in contact isolation, failed to maintain infection control for 1 resident (Resident #96) with a foley catheter, and failed to maintain infection control during the medication administration for 1 resident (Resident #28) of 16 residents reviewed. The findings include: Review of the facility policy Isolation Precautions not dated revealed, .Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . […]

• No harm, potential for more than minimal, isolatedF600Dec 3, 2025

  Based on review of facility policy, review of medical records, review of facility investigation documentation, and interviews, the facility failed to protect the residents' right to be free from physical abuse by a staff member for 1 resident (Resident #21) of 15 residents reviewed for abuse. The facility was cited at Past Non-Compliance for F-600. Non-compliance began on 6/1/2025 and ended on 6/6/2025.The facility is not required to submit a Plan of Correction for F-600.The findings include:Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse… […]

• No harm, potential for more than minimal, isolatedF644Dec 3, 2025

  Based on review of facility policy, review of medical records, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis was added for 1 resident (Resident #9) of 5 residents reviewed for PASARR.The findings include: Review of the facility's undated policy titled, Coordination with PASARR Program, revealed .This facility coordinates assessments with the .[PASARR] program .to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services .appropriate to their needs .any level II resident who experiences a significant change in status will be referred promptly to the mental health or intellectual disability authority for additional resident review… […]