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Complaint Investigation

Four Oaks Health Care Center

March 5, 2025 · Jonesborough, TN · 1101 Persimmon Ridge Rd
Citations 1
CMS Rating 4/5
Beds 84
Provider ID 445458
Healthcare Facility
Four Oaks Health Care Center
Jonesborough, TN  ·  View full profile →
Inspection Summary

FOUR OAKS HEALTH CARE CENTER in JONESBOROUGH, TN — inspection on March 5, 2025.

Found 1 citation. 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.

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Inspection Findings

FF689
Minimal harm or the facility .He mentioned that he had secured a place in Kingsport and was going to social security [office] Few calling police a note was found that stated he had decided to leave .His letter is consistent with the plans he affected

Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Traumatic Hemorrhage of Cerebrum, Fracture of Base of Skull, and Depression.

Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 required set up assistance with activities of daily living (ADL's). Resident #6 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment

Review of the care plan for Resident #6 dated 8/16/2024 and revised on 10/6/2024 revealed .Resident is at risk for elopement [related to] cognitive impairment, exhibits unsafe wandering behaviors, has expressed desire to leave .Resident prepared letter of plan of living arrangements, including monetary means .Resident will be safe in facility and will not exit facility unsupervised .Distract resident from wandering by offering pleasant diversions, structured activities, food .

Review of the facility investigation documentation revealed on 10/6/2025 at 12:30 AM, staff became aware Resident #6 was not in the facility. Resident #6 had broken the lock on his bedroom window and exited the building through the window.

The resident left a note stating he did not want to stay at the facility any longer.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

445458

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 445458 B.

Wing 03/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Four Oaks Health Care Center 1101 Persimmon Ridge Rd Jonesborough, TN 37659

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in JONESBOROUGH, TN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FOUR OAKS HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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