Inspection Reports for Four Oaks Senior Living
565 Boyette Road Four Oaks, NC 27524, Four Oaks, NC, 27524
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
67% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 4
Date: Aug 28, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey and a complaint investigation initiated by the Johnston County Department of Social Services on August 15, 2025, to assess compliance with health care and medication administration regulations.
Complaint Details
Complaint investigation initiated by Johnston County Department of Social Services on August 15, 2025, related to health care and medication administration concerns.
Findings
The facility failed to ensure appropriate referral and follow-up for a resident's acute health care needs, including podiatry and physical therapy referrals. Medication administration errors were observed, including incorrect dosing, failure to administer medications with meals as ordered, and inaccurate medication administration records.
Deficiencies (4)
Failed to ensure referral and follow-up to meet acute health care needs for Resident #3, including notifying the primary care provider about overgrown and discolored toenails and a referral for physical therapy evaluation.
Failed to ensure medications were administered as ordered for Resident #9, including errors with pain medication, constipation medication, and potassium supplement.
Failed to ensure medication administration records were accurate for Resident #1 regarding an inhaler used to treat chronic obstructive pulmonary disease.
Failed to implement an increased medication order for Resident #4; Atorvastatin dose was not increased as ordered due to pharmacy not receiving the order.
Report Facts
Medication error rate: 12
Medication administration occasions: 53
Medication administration documented: 39
Medication administration refusals: 14
Doses documented after inhaler opened: 19
Resident #4 Atorvastatin 40mg administration exceptions: 4
Inspection Report
Follow-Up
Census: 64
Capacity: 96
Deficiencies: 4
Date: Jun 20, 2025
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 06/19/25 to 06/20/25 to verify correction of previous deficiencies.
Findings
The facility failed to provide a safe and clean environment free of hazards related to bed bugs in residents' rooms on the 400 Hall in the assisted living side. Additionally, the HVAC system controlling the library and hallway on the 400 Hall was not maintained in operating condition. Medication administration errors were found for multiple residents, including incorrect administration of medications and failure to follow orders.
Deficiencies (4)
Facility failed to provide a safe and clean environment free of hazards related to bed bugs in residents' rooms on the 400 Hall in the assisted living side.
Facility failed to ensure the HVAC system controlling the library and hallway on the 400 Hall was maintained in operating condition.
Facility failed to ensure medications were administered as ordered for multiple residents, including errors with medication for congestion and cough, vitamin supplements, blood thinner, antibiotic, and topical pain reliever.
Medication administration records were not accurate for multiple residents, including documentation for medication for cough and congestion and vitamin supplements.
Report Facts
Facility licensed capacity: 96
Facility census: 64
Residents in SCU: 33
Residents in AL: 31
Medication error rate: 6
Temperature: 79
Bed bug affected rooms: 3
Bed bug follow-up timeframe: 14
Warfarin doses administered incorrectly: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator / Executive Director | Interviewed regarding bed bug issues, pest control procedures, and HVAC problems. | |
| Exterminator | Interviewed regarding bed bug treatment and facility compliance with pre-treatment protocol. | |
| Personal Care Aide (PCA) | Interviewed regarding bed bug procedures and clothing handling. | |
| Maintenance Staff | Interviewed regarding HVAC issues and bed bug pre-treatment preparation. | |
| Housekeeper | Interviewed regarding bed bug activity and HVAC conditions. | |
| Medication Aide (MA) | Interviewed regarding medication administration errors and procedures. | |
| Resident Care Coordinator (RCC) | Interviewed regarding medication order verification and communication. | |
| Certified Pharmacy Technician | Interviewed regarding pharmacy order processing and medication dispensing. | |
| Primary Care Providers | Interviewed regarding medication orders and resident care. |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 7
Date: Mar 27, 2025
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey on March 26-27, 2025.
Findings
The facility was found deficient in maintaining a hazard-free environment in the Special Care Unit (SCU), ensuring consistent heating, maintaining safe hot water temperatures, serving therapeutic diets as ordered, and administering medications accurately including seizure medication.
Deficiencies (7)
Facility failed to maintain an environment free of hazards as personal care and cleaning products were unsecured in residents' rooms in the SCU.
Facility failed to ensure a heating unit was maintained in operating condition consistently for approximately five months.
Facility failed to ensure portable electric heaters were not used in residents' rooms on the 400 hall.
Facility failed to maintain hot water temperatures between 100 to 116 degrees Fahrenheit in residents' bathrooms; 4 of 5 fixtures exceeded this range.
Facility failed to ensure a therapeutic diet was served as ordered for 1 of 5 sampled residents (#4) with a mechanical soft with chopped meat diet order.
Facility failed to ensure medications were administered as ordered for 1 of 6 residents (#6), including failure to administer phenytoin sodium (seizure medication) for six days.
Facility failed to ensure medication administration records were accurate for 2 of 6 sampled residents (#5, #6) related to documentation of fingerstick blood sugar levels and seizure medication administration.
Report Facts
Residents on Special Care Unit: 32
Hot water temperature: 121.6
Hot water temperature: 117.8
Phenytoin sodium administration gap: 6
Lantus insulin pen dosage: 18
FSBS check times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Aide (PCA) | Interviewed regarding storage of personal care products and cleaning supplies in SCU | |
| Medication Aide (MA) | Interviewed regarding medication administration and storage practices | |
| Special Care Coordinator (SCC) | Interviewed regarding personal care product storage and diet order communication | |
| Administrator | Interviewed regarding facility policies on personal care product storage, heating, water temperature, and medication administration | |
| Regional Vice President of Operations (RVPO) | Interviewed regarding HVAC unit installation and portable heater use | |
| Regional Maintenance Director (RMD) | Interviewed regarding heating unit maintenance and thermostat settings | |
| Cook | Interviewed regarding diet order communication and meal preparation | |
| Resident Care Coordinator (RCC) | Interviewed regarding diet order communication and medication administration | |
| Primary Care Provider (PCP) | Interviewed regarding diet orders and medication prescriptions | |
| Memory Care Coordinator (MCC) | Interviewed regarding medication administration record accuracy |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 6, 2024
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on February 6, 7, and 8, 2024, to verify correction of previous deficiencies related to healthcare referral and follow-up and implementation of physician orders.
Findings
The facility failed to ensure healthcare referral and follow-up for one sampled resident related to an unperformed EKG ordered on 01/16/24, and failed to implement physician orders for monitoring blood pressure and adjusting medication for another resident. There was no system in place to ensure all PCP visit notes and orders were reviewed and implemented timely.
Deficiencies (2)
Failure to ensure healthcare referral and follow-up related to failure to implement physician's orders for an electrocardiogram (EKG) for Resident #2.
Failure to ensure documentation and implementation of physician orders for monitoring blood pressure and adjusting medication for Resident #4.
Report Facts
Dates of survey: 3
Days BP monitoring order missed: 7
Inspection Report
Routine
Capacity: 96
Deficiencies: 14
Date: Jan 25, 2024
Visit Reason
The facility was surveyed for conformance with applicable licensing and building code requirements, including a Construction Section Biennial Survey and compliance with adult care home physical plant rules.
Findings
Multiple deficiencies were cited including lack of schematic wiring diagrams, inadequate emergency release key distribution, missing current fire and safety inspection reports, absence of wanderer alarms on exit doors, poor maintenance of outside premises, housekeeping and furnishings issues, fire safety equipment and building maintenance problems, and inadequate exhaust ventilation in specified areas.
Deficiencies (14)
No schematic wiring diagram of the special locking system displayed adjacent to the fire alarm panel.
Only one staff member had emergency release switch keys for the special locking system, and the key was not on her person.
Facility did not have current fire and building safety inspection reports available; most recent fire sprinkler inspection dated April 25, 2019.
Exit doors accessible to residents in the Special Care Unit lacked sounding devices activated when doors are opened.
Outside premises not maintained in a clean and safe condition with multiple areas of siding damage, roof patches, rotting trim, and mildew.
Ceilings, floors, walls, and furnishings were not kept clean and in good repair, including peeling ceiling finish, stained and damaged flooring, urine odor, roaches, and broken fixtures.
Facility not maintained free from hazards; obstructions in exit paths, improperly stored oxygen bottles, and door hardware issues.
Fire safety systems not maintained in safe condition; missing sprinkler escutcheon rings, unsealed penetrations, cracked ceilings, damaged doors not closing or latching properly.
Electrical equipment not maintained safely; non-functioning alarms, broken call bell system, malfunctioning keypad, open junction box, broken outlet cover plates.
Fire safety equipment not inspected or maintained; fire extinguisher missed monthly inspection.
Electrical emergency/safety lighting and exit signs not functioning properly, failing to illuminate on test.
Exhaust ventilation not maintained in specified spaces including shower rooms, soiled utility rooms, and bathrooms, causing humidity and odor issues.
Facility did not provide towel bars in bedrooms or adjoining bathrooms for each resident.
Fire safety rehearsals records did not include staff members present.
Report Facts
Licensed beds: 96
Special Care Unit beds: 40
Date of last fire sprinkler inspection: Apr 25, 2019
Oxygen bottles improperly stored: 5
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 11
Date: Dec 1, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey and complaint investigation from November 28, 2023 through December 1, 2023.
Complaint Details
The inspection included a complaint investigation as stated in the initial comments.
Findings
The facility failed to ensure the special care unit environment was clean, orderly, and free of hazards including cleaning chemicals, sharp objects, and personal care products. There were multiple medication administration errors, failure to provide personal care and supervision, failure to follow up on health care needs, lack of activities program, and failure to monitor exit doors when the magnetic locking system failed.
Deficiencies (11)
Failed to ensure the special care unit environment was clean, orderly, and free of hazards including cleaning chemicals, sharp objects, and personal care products.
Failed to ensure a reliable heating system sufficient to maintain 75 degrees Fahrenheit under winter conditions in one room on the Assisted Living and one room on the Special Care Units.
Failed to ensure water temperatures on the Special Care Unit and Assisted Living were consistently maintained between 100 and 116 degrees Fahrenheit.
Failed to complete an assessment and care plan for 1 sampled resident with significant change in mobility, repeated falls, and pressure wounds.
Failed to provide personal care assistance including repositioning, nail care, bathing, and toileting for 3 sampled residents resulting in development and worsening of pressure wounds, unclean fingernails, and increased risk of skin breakdown.
Failed to provide supervision for 2 sampled residents who required increased supervision for repeated falls with injuries, resulting in risk for serious physical harm.
Failed to ensure health care follow up with the provider for 4 sampled residents who required monthly blood levels for monitoring and dosage adjustment of an anticoagulant, contacting the home health agency for acute wound care, reporting of low blood pressures to the provider, and scheduling an orthopedic referral appointment following a lumbar fracture.
Failed to ensure residents were provided an activities program; no activities were observed at scheduled times and the activities coordinator position was eliminated without a replacement or process to continue activities.
Failed to ensure medications were administered as ordered for 3 sampled residents and 3 residents observed during medication pass, including errors with insulin pen technique, crushing extended-release medication, improper inhaler administration, failure to administer topical cream due to unavailability, failure to hold laxative for diarrhea, and failure to hold diuretic based on blood pressure parameters.
Failed to ensure the medication administration records were accurate for 2 sampled residents including inaccurate documentation for a medication for heart and blood pressure, a topical cream for inflammatory skin conditions, bed alarm checks, and activity checks.
Failed to ensure there was a system of monitoring exit doors on the Special Care Unit when the magnetic locking system failed.
Report Facts
Residents in SCU: 34
Medication error rate: 12
Temperature in resident room #315: 61.6
Temperature in resident room #315: 62.5
Hot water temperature: 127
Hot water temperature: 130
Hot water temperature: 63
Hot water temperature: 65
Blood pressure: 80
Blood pressure: 81
Blood pressure: 89
Blood pressure: 94
Blood pressure: 106
Blood pressure: 107
Blood pressure: 112
Blood pressure: 118
Blood pressure: 120
Medication administration opportunities: 32
Medication administration errors: 4
Bed alarm documentation: 30
Bed alarm removed: 1
Fall monitoring duration: 3
Fall monitoring duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Special Care Coordinator | Special Care Coordinator | Named in multiple interviews related to findings and deficiencies |
| Administrator | Administrator | Named in multiple interviews related to findings and deficiencies |
| Maintenance Person | Maintenance Person | Named in interviews related to generator and maglock issues |
| Medication Aide | Medication Aide | Named in interviews related to medication administration errors |
| Personal Care Aide | Personal Care Aide | Named in interviews related to personal care and supervision deficiencies |
| Resident Care Coordinator | Resident Care Coordinator | Named in interviews related to fall monitoring and care plans |
| Regional Nurse | Regional Nurse | Named in interviews related to licensed health professional support assessments |
| Home Health Nurse | Home Health Nurse | Named in interviews related to wound care follow-up |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
The visit was conducted as a Death Investigation following the discovery of a resident found non-responsive and deceased at the facility.
Complaint Details
The complaint investigation was substantiated as the facility failed to ensure CPR was initiated by qualified staff for a resident found not breathing and without a pulse, resulting in substantial risk for serious harm.
Findings
The facility failed to ensure that staff responded immediately with CPR for one resident who required cardiopulmonary resuscitation, resulting in a Type A2 violation. Staff A, whose CPR certification had expired, failed to alert CPR-certified staff, and the resident was pronounced dead by EMS shortly after arrival.
Deficiencies (1)
Staff failed to respond immediately for 1 resident requiring CPR according to facility policies and training.
Report Facts
Plan of Correction penalty amount: 400
Number of visits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed to initiate CPR, CPR certification expired, resigned at start of investigation | |
| Staff B | CPR certified, supervisor for building shift, was in another resident's room during incident | |
| Kendryn Wheeler | Administrator | Received the CAR report |
Inspection Report
Follow-Up
Census: 88
Capacity: 96
Deficiencies: 3
Date: Jan 21, 2022
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey with an onsite visit from January 19, 2022 to January 20, 2022 and a desk review survey on January 21, 2022 with a telephone exit on January 21, 2022.
Findings
The facility failed to ensure two of five exit doors accessible to residents had sounding devices activated for safety for nine sampled residents assessed to be intermittently disoriented and wanderers. The heating system failed to maintain 75 degrees Fahrenheit under winter conditions, resulting in residents feeling cold and uncomfortable. Additionally, the facility failed to implement CDC and NCDHHS COVID-19 guidance related to timely testing of residents in the Assisted Living section during a COVID-19 outbreak in the Memory Care Unit.
Deficiencies (3)
Two of five exit doors accessible for residents' use on the Assisted Living sections lacked a sounding device that activated for safety for nine sampled residents who were intermittently disoriented and wanderers.
The heating system failed to maintain a temperature of 75 degrees Fahrenheit under winter conditions resulting in residents feeling cold and uncomfortable.
The facility failed to ensure implementation of CDC and NCDHHS guidance for COVID-19 testing for residents in the Assisted Living section during a COVID-19 outbreak.
Report Facts
Residents tested positive for COVID-19: 16
Licensed capacity: 96
Resident census: 40
Resident census: 48
Exit doors without sounding device: 2
Sampled residents with disorientation and wandering: 9
Temperature readings: 66
Temperature readings: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding sounding devices, heating issues, and COVID-19 testing procedures. | |
| Medication Aide/Personal Care Aide | Interviewed about sounding device functionality and resident wandering. | |
| Medication Aide/Supervisor | Interviewed about Resident #1 wandering behavior. | |
| Maintenance Person | Interviewed about door alarms and heating system issues. | |
| Resident Care Manager | Interviewed about COVID-19 testing and outbreak management. | |
| Divisional Clinical Director | Interviewed about COVID-19 testing and infection control procedures. | |
| COVID-19 Response Team Member | Interviewed from county health department regarding outbreak and testing guidance. | |
| Repair Technician | Interviewed about heating unit repairs and auxiliary heat strip needs. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 29, 2021
Visit Reason
The Adult Care Licensure Section conducted an annual survey from October 27, 2021 to October 29, 2021.
Findings
The facility failed to ensure personal care assistance including incontinent care and nail care for Resident #1, failed to provide supervision for a fall risk resident, failed to implement physician's orders for compression stockings for Resident #8, failed to follow COVID-19 visitation and quarantine guidance resulting in resident isolation and restricted movement, failed to administer rapid acting insulin as ordered for Residents #3 and #9, and failed to provide accessible lockable space for residents' personal belongings.
Deficiencies (8)
Failed to ensure staff provided personal care assistance to Resident #1 including incontinent care and nail care.
Failed to provide supervision according to interventions for Resident #1 identified as a risk for falls.
Failed to ensure physician's orders were implemented for Resident #8 related to compression stockings.
Failed to ensure residents' rights were maintained related to visitation, restriction of movement, and smoking schedule adherence.
Failed to ensure medications were administered as ordered for Residents #3 and #9 with orders for rapid acting insulin before meals.
Failed to ensure residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to personal care.
Failed to ensure residents were free of mental and physical abuse, neglect, and exploitation related to residents' rights.
Failed to provide accessible lockable space to residents related to locking closet doors in resident rooms and not providing keys to residents.
Report Facts
Deficiencies cited: 8
Correction date: 2021
FSBS values: 493
FSBS values: 278
FSBS values: 224
FSBS values: 249
FSBS values: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Responsible for overseeing medication aides and ensuring medication orders are followed |
| Administrator | Facility Administrator | Provided multiple interviews regarding visitation, quarantine, and facility policies |
| Medication Aide | Medication Aide (MA) | Observed administering insulin and managing residents' cigarettes |
| Primary Care Provider | Resident's Primary Care Provider (PCP) | Interviewed regarding Resident #1 and Resident #9 care |
| Activity Director | Activity Director (AD) | Assisted with personal care for Resident #1 |
Inspection Report
Capacity: 136
Deficiencies: 10
Date: May 16, 2018
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and relevant North Carolina Building Codes and Rules for Licensing of Adult Care Homes.
Findings
Multiple deficiencies were cited related to housekeeping, maintenance, fire safety, and ventilation. Specific issues included damaged doors, peeling paint, unfastened ceiling sheet-rock, improper storage of oxygen cylinders, fire safety equipment not properly maintained, and non-operational mechanical ventilation in certain areas.
Deficiencies (10)
Kitchen entry door from the Dining Hall has wood veneer that is delaminating and edges are damaged.
Ceiling sheet-rock has become unfastened from the supporting structure in Room 415.
Ceiling paint is peeling in the Bathroom shared by Rooms 313/315.
Floor areas that meet the corridors have run-off spotting from cleaning agents and wax resulting in incomplete floor finishes.
Oxygen gas cylinders located in the Assisted Living Med Room are free-standing and not in storage racks.
Ansul spray nozzles are not directed to the cooking surfaces on the range because the unit has been moved away from the back wall.
Escutcheon does not cover an opening in the ceiling construction located in the back closet for Room 307.
Kitchen emergency wall light does not operate.
Facility failed to exhaust ventilation at the rate of two cubic feet per minute per square foot.
Mechanical ventilation system is not operational at the First Shower/300 Hall and Janitor Closet adjacent to Smoke Area.
Report Facts
Total licensed beds: 96
Special Care Unit beds: 40
Inspection Report
Follow-Up
Deficiencies: 2
Date: Aug 25, 2016
Visit Reason
This report is of a Followup Survey conducted to verify correction of previously identified deficiencies at Oakview Commons.
Findings
The followup survey revealed that all deficiencies have not been corrected. Observations included incomplete repairs to walls, ceilings, and floors, and fire safety equipment not maintained in safe operating condition, including issues with evacuation keys, door latches, and firestopping materials.
Deficiencies (2)
Walls, ceilings, and floors are not clean and in good repair; door frames gouged and scarred requiring touch-up painting and repair; corridor walls marred requiring touch-up painting and repair.
Fire safety equipment not maintained in working order; staff responsible for evacuation did not carry keys for keyed manual override switch; one leaf of double doors did not latch; gap around piping for water heater penetrates fire resistant rated ceiling with unrated fire foam used to firestop.
Report Facts
Percentage of repair work completed: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bob Getchell | Surveyor who conducted the followup survey on August 25, 2016. |
Inspection Report
Annual Inspection
Capacity: 96
Deficiencies: 9
Date: Jun 22, 2016
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and Rules for Licensing of Adult Care Homes in effect at the time of initial licensure. This was a biennial survey.
Findings
The inspection found multiple deficiencies including unclean and damaged walls, ceilings, and floors; lack of required furnishings such as individual towel bars in shared bathrooms; and fire safety equipment not maintained in working order, including issues with fire alarm panels, exit door manual overrides, emergency lighting, door latches, and penetrations in fire resistant ceilings.
Deficiencies (9)
Walls, ceilings, and floors are not clean and in good repair; door frames gouged and scarred requiring touch up painting and repair; corridor walls marred.
Shared resident bathroom floors are not clean.
HVAC grilles clogged with dust and particulate.
Resident bathrooms shared by two double occupancy rooms do not have a separate towel bar for each resident.
Fire alarm panel indicating a 'trouble' with the lobby duct smoke detector.
Key for keyed manual override switch for magnetic door lock did not operate the switch; staff unaware of purpose and did not have keys.
Exit signs not working on house current or battery power in 300 Hall and Private Dining Room.
Doors (library double doors and cross corridor doors adjacent to soiled linen room) did not latch; latch mechanisms would not operate.
Gap around piping for water heater where it penetrates the fire resistant rated ceiling.
Report Facts
Licensed capacity: 96
Inspection Report
Deficiencies: 2
Date: Jan 30, 2015
Visit Reason
The inspection was conducted to assess compliance with tuberculosis testing requirements and resident rights at Oakview Commons, following regulatory standards for adult care homes.
Findings
The facility failed to ensure all residents were tested for tuberculosis upon admission as required, with documentation missing for Resident #7. Additionally, the facility did not assure residents were treated with respect and dignity, with multiple residents reporting disrespectful staff behavior and early morning disturbances.
Deficiencies (2)
Failure to assure each resident had tuberculosis testing upon admission in compliance with control measures, evidenced by missing documentation for Resident #7.
Failure to assure residents' rights to respect, dignity, and privacy, with reports of disrespectful staff behavior and residents being dressed early in the morning against their wishes.
Report Facts
Sampled residents for TB testing: 7
Sampled residents for respect and dignity: 8
Resident complaints: 2
Report
Sep 9, 2016
Viewing
Loading inspection reports...
