Five Oaks Rehabilitation And Care Center
Five Oaks Rehabilitation and Care Center in Concord, NC — inspection on March 16, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observations and staff interviews, the facility failed to remove expired medications stored
Rooms for 200 and 300 halls and Medication Cart #3).The findings included:a. An observation of Medication Room for the 300 hall was conducted on 3/10/2026 at 12:22 PM in the presence of Nurse #2.
The following medication was found in the medication room: one bottle of Jardiance 10 milligrams (mg) with 30 tablets (medication used to control blood sugar levels).
The expiration date on the bottle was 2/17/2026.
Nurse #2 confirmed the expiration date by reading aloud the date printed on the bottle. An interview with Nurse #2 was completed on 3/10/2026 at 12:25 PM.
Nurse #2 reported the Unit Manager for the 300 hall would check the medication room weekly for expired medications.The interview conducted on 3/10/2026 at 12:27 PM with the 300 Hall Unit Manager revealed that she had been working at the facility for 2 months and needed to confirm with the Director of Nursing (DON) how often the Medication Room should be checked for expired medications. b.
Nurse #2 remained present during the observation of Medication Cart #3 on 3/10/2026 at 12:47 PM.
The observation revealed one box of Ocusoft eye cleanser wipes, 18 individually wrapped.
The expiration date printed on the box was 10/2025.
Nurse #2 confirmed the expiration date by reading aloud the date printed on the box. An interview with Nurse #2 on 3/10/2026 at 12:50 PM revealed that she was assigned to Medication Cart #3.
Nurse #2 stated she checked her cart prior to each shift for expired medications and needed supplies.
Nurse #2 reported she had checked Medication Cart #3 at the beginning of her shift but must have missed the box of eye cleanser pads. c. An observation of the Medication Room for the 200 hall was conducted on 3/10/2026 at 1:19 PM in the presence of Nurse #3.
The following medication was found in the refrigerator: Promethegan 12.5 mg suppositories (medication used to treat nausea, vomiting, allergies, and for sedation) in a box containing 6 suppositories with the expiration date 1/2026.
Nurse #3 confirmed the expiration date by reading aloud the expiration date printed on the box and suppositories. An interview with Nurse #3 was completed on 3/10/2026 at 1:22 PM.
Nurse #3 stated that the unit managers are responsible for checking the medication rooms for expired medications weekly and a night shift nurse should check the medication room each night shift.
Nurse #3 reported that if an expired medication was found, a return form should be completed and placed in return in for pharmacy to pick up on night shift.
The interview conducted with the DON on 03/13/2026 at 12:48 PM revealed that each unit manager checks medication expiration dates weekly in the medication rooms and medication carts.
The DON reported that nurses should check their medication carts prior to each shift and the night shift nurses are to check for expired medications in the medication rooms.
The DON stated that medication expirations dates were checked because expired medications could lose their effectiveness or become more potent over time. An interview was completed on 3/13/2026 at 1:56 PM with the Administrator.
The Administrator stated that he would refer to the DON for the process regarding staff checking for medication expiration dates.
neckline of her gown and revealed a central line catheter (a long flexible tube inserted into a large
room carrying a pair of gloves. Resident #24's room had an Enhanced Barrier Precautions (EBP) sign posted to the right side of the door and personal protective equipment (PPE) was located outside of the door in a plastic 2-drawer storage container.
The EBP sign indicated that everyone must clean their hands before entering and leaving the room.
The sign went on to state that all healthcare personnel must wear gloves and a gown for the following high contact resident care activities: dressing/bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care for any skin opening requiring a dressing. NA #3 was not wearing a gown. NA #3 was observed after several minutes walking around the end of Resident #24's bed. NA #3 was wearing gloves but continued care without donning a gown. NA #3 was observed walking to Resident #24's closet and obtaining an item from the closet, returned to the bedside and was not wearing a gown.
Upon completion of care for Resident #24, NA #3 exited the room wearing gloves and carrying a clear bag of trash.
An interview with NA #3 was conducted on 3/10/2026 at 1:40 PM as she exited Resident #24's room.
NA #3 was shown the Enhanced Barrier Precautions sign and asked what it meant. NA #3 stated she was aware Resident #24 was on Enhanced Barrier Precautions due to open wounds and infections. NA #3 stated a gown was only required when performing dressing changes.
An interview was conducted 3/12/2026 at 1:30 PM with the Infection Preventionist.
She stated that NA #3 should have worn both gloves and a gown when entering the room to provide high contact care to Resident #24 due to Resident #24's open wounds on her sacrum and current infections.
The Infection Preventionist indicated that the Enhanced Barrier Precaution sign was posted next to the door and NA #3 had received training on Enhanced Barrier Precautions during orientation when hired and yearly through online training modules.
An interview on 3/13/2026 at 12:44 PM with the Director of Nursing (DON) revealed Resident #24 had open wounds, infections, and a central line.
Due to Resident #24 requiring Enhanced Barrier Precautions for these conditions, NA #3 should have worn both gown and gloves when she provided care to Resident #24.
An interview was conducted on 3/13/2026 at 1:55 PM with the Administrator.
The Administrator stated he expected staff to wear the required PPE when providing care to residents on Enhanced Barrier Precautions.
345186 03/16/2026
Five Oaks Rehabilitation and Care Center 413 Winecoff School Road Concord, NC 28027