Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Franklin Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the dumpster area was not maintained free of leakage and pooled spillage, with a significant buildup of gray sludge and milky liquid spreading from the dumpster. Staff confirmed the issue was due to a recently replaced, leaking dumpster, and that all staff were expected to report such concerns to management.
The facility did not provide written notification of grievance investigation outcomes or corrective actions to residents who filed complaints, despite conducting investigations and taking actions such as staff retraining and room cleaning. Three cognitively intact residents reported not receiving written or verbal resolutions, and documentation was incomplete or missing on grievance forms. Staff and administration confirmed that written responses were only given if requested, and the Administrator was unaware of the requirement for written documentation.
A resident with a history of major depressive disorder and anxiety was newly diagnosed with bipolar disorder with depression, but the facility did not complete a required Level II PASRR referral following this significant change. The Social Worker, responsible for PASRR referrals, was unaware that the referral had not been made, and the oversight was discovered during record review and staff interviews.
The facility failed to maintain ongoing communication with the dialysis treatment center for a resident with ESRD, as 18 out of 50 dialysis communication forms were not completed by staff. Interviews revealed inconsistencies and a lack of a process to ensure the forms were filled out, despite the importance of these forms for resident care.
The facility failed to provide pureed food items with a smooth consistency, as required for residents with diet orders for a pureed diet texture. During a lunch meal tray line observation, the pureed chicken pastry was found to have a lumpy consistency, which was confirmed by the Cook and Nutrition Consultant. The Dietary Manager, Registered Dietitian, and Speech Language Pathologist all emphasized the importance of smooth, lump-free pureed foods to prevent choking and other risks.
The facility failed to allow cook pans and dome lids to completely dry before stacking, and did not adequately clean the convection ovens. Observations revealed wet nesting of pans and dome lids, and grease and black substance buildup in the ovens. The Dietary Manager and Administrator acknowledged these issues and the need for proper drying and cleaning techniques.
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of fly activity in the kitchen. Despite monthly pest control services and the use of insect light traps, the facility struggled with fly infestations due to frequent issues with the traps and high traffic areas. The Dietary Manager and Maintenance Director confirmed the presence of flies, and the Administrator acknowledged the difficulty in keeping the kitchen fly-free.
The facility failed to invite a cognitively intact resident to participate in the care planning process. Despite multiple scheduled care plan meetings with the resident's Responsible Party, there was no documentation or evidence that the resident was invited or involved. Interviews with staff revealed a lack of communication and follow-through in ensuring the resident's participation.
The facility failed to complete a Minimum Data Set (MDS) significant change assessment within 14 days for a resident using a soft belt restraint. The resident, diagnosed with dementia, had a physician's order for the restraint, but the assessment was completed late. The MDS Nurse acknowledged the delay without providing a reason, and the Administrator confirmed the nurse's responsibility for timely completion.
The facility failed to accurately code the MDS assessment for a resident with dementia who had an active order for a soft belt restraint. Despite documentation in the care plan and nursing notes, the restraint was not coded in the MDS quarterly assessment due to an oversight by the MDS Nurse Consultant.
A facility failed to maintain a complete and accurate medical record for a resident with dysphagia. Despite the resident and staff confirming a signed waiver for regular food and thin liquids, the waiver was not found in the medical record, indicating a lapse in documentation.
The facility's QAA Committee failed to maintain procedures and monitor interventions for infection prevention and control, leading to a recited deficiency. Observations included improper handling of soiled linen by a laundry aide and a staff member entering a quarantine room without PPE. An interview revealed no current monitoring plans were in place.
The facility failed to handle visibly soiled and wet linen to avoid contamination of staff clothing. A laundry aide was observed handling soiled linen without wearing an apron or gown, contrary to facility policy. Interviews revealed inconsistent education and understanding of PPE requirements among staff.
Improper Maintenance of Dumpster Area Leading to Unsanitary Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain the dumpster area free of leakage and pooled spillage. On two separate occasions, a 22-foot-long compact dumpster was found with a 6 inch by 4-inch buildup of gray sludge on its exterior bottom rim, from which a large pool of milky grey liquid had formed, initially measuring 6 feet long and later spreading up to 18 feet away from the dumpster. Staff interviews confirmed that the leaking dumpster had recently been replaced by the trash company and that all staff were expected to report concerns with the area to management. These observations and staff statements indicate that the facility did not ensure proper disposal of garbage and refuse, resulting in unsanitary conditions around the dumpster.
Failure to Provide Written Notification of Grievance Outcomes
Penalty
Summary
The facility failed to notify residents and their representatives of the results of grievance investigations and any corrective measures taken, as required by its own policy. Record review and interviews revealed that for three cognitively intact residents who filed multiple grievances, there was no documentation that they received written notification of the investigation outcomes or the decisions made regarding their concerns. The grievance forms often lacked completion in sections related to outcome expectations, actions taken, and resolution, with only the Administrator's signature present. One resident filed a grievance about staff not assisting her to the bathroom after answering her call bell. The investigation led to staff retraining, but there was no documentation that the resident was informed of the outcome, either verbally or in writing. Another resident filed grievances regarding improper administration of eye drops and the presence of ants in his room. Investigations were conducted, and actions such as staff training and room cleaning were taken, but again, there was no evidence that the resident was notified of the results. A third resident filed several grievances, including concerns about missed insulin doses, room temperature, and improper glove use by staff. The investigations were completed, but the forms were incomplete, and there was no documentation of notification to the resident. Interviews with staff and administration confirmed that grievance outcomes were typically communicated verbally, and written responses were only provided upon request. The Administrator was unaware of the requirement for written documentation of grievance outcomes.
Failure to Refer Resident for Level II PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly identified serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR). The resident was originally admitted with diagnoses of major depressive disorder and recurrent anxiety disorder, and a Level I PASRR was completed at that time, indicating that no further screening was required unless a significant change in mental health status occurred. On a later date, the resident received a new diagnosis of bipolar disorder with depression, which constitutes a significant change and requires a Level II PASRR referral. Record review showed there was no documentation that a Level II PASRR referral was completed after the new diagnosis. The resident's annual Minimum Data Set (MDS) assessment confirmed the absence of a Level II PASRR. During interviews, the Social Worker acknowledged responsibility for submitting PASRR referrals and stated that new mental health diagnoses were reviewed daily in interdisciplinary meetings, but this resident had been overlooked. The Administrator confirmed that the Social Worker was responsible for the PASRR review process.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis treatment center for a resident with end stage renal disease (ESRD) who required dialysis. The resident had an active physician order for dialysis on Monday, Wednesday, and Friday, and the care plan included an intervention to communicate with the dialysis treatment center. However, a review of the resident's dialysis communication notebook revealed that 18 out of 50 dialysis communication forms were not completed by the facility staff prior to the resident's dialysis treatments. These forms lacked essential information such as the resident's name, primary care physician, date, vital signs, medications administered, diet, fluid restrictions, access site assessment, significant alerts, and the name of the facility nurse. Interviews with multiple nurses assigned to the resident on dialysis days revealed inconsistencies in completing the dialysis communication forms. Some nurses were unable to recall if they were responsible for the incomplete forms, while others admitted to being too busy to fill them out. The Unit Manager and Director of Nursing (DON) confirmed that the forms should have been completed and sent with the resident to the dialysis treatment center. The DON acknowledged that the facility did not have a process in place to ensure the completion of these forms. The Medical Director emphasized the importance of these forms for communication with the dialysis treatment center, and the Administrator confirmed that the nurses were responsible for completing them on dialysis days.
Failure to Provide Properly Pureed Foods
Penalty
Summary
The facility failed to provide pureed food items with a smooth consistency, as required for residents with diet orders for a pureed diet texture. During a lunch meal tray line observation, the pureed chicken pastry was found to have a lumpy consistency. The Cook, who had prepared the meal, acknowledged that the consistency should be smooth like pudding. The Nutrition Consultant also confirmed the presence of lumps and requested the Cook to further blend the pureed items. The Dietary Manager and Registered Dietitian both stated that pureed foods should be smooth and lump-free, and the Speech Language Pathologist highlighted the risks associated with serving lumpy pureed foods, such as choking and pocketing. Despite these standards, the facility did not consistently ensure the proper preparation of pureed foods, potentially affecting 21 residents with diet orders for a pureed diet texture. Interviews with the Dietary Manager, Registered Dietitian, and Speech Language Pathologist revealed that none of them had previously observed or received complaints about lumpy pureed foods. The Dietary Manager suggested that the Cook, who had been with the facility for many years, might have been nervous or made an oversight. The Administrator confirmed that any pureed foods with lumps would need to be further blended to achieve the proper consistency. The facility's failure to consistently provide pureed foods with the required smooth consistency was identified as a deficiency during the survey.
Improper Drying and Cleaning Procedures in Kitchen
Penalty
Summary
The facility failed to allow cook pans and dome lids to completely dry prior to assemblage and stacking, as observed during multiple inspections. Twelve steam table pans were found stacked wet and ready for reuse, and the Dietary Manager (DM) acknowledged that the pans should be air-dried and stacked at an angle to prevent wet nesting. Further observations revealed that water dripped from a dome lid onto a plated meal, and fifty-two dome lids were observed with wet nesting on the inside edge. The DM admitted that staff had been trained on proper placement to prevent wet nesting, but the issue persisted. The Administrator confirmed the presence of water on the inside edge of the dome lids and acknowledged the need for staff re-education on proper drying techniques. Additionally, the facility failed to clean the convection ovens adequately. The top oven had a thick, black layer on the bottom and brown grease covering the glass doors, while the bottom oven had grease-covered glass doors. The DM stated that the ovens were due for cleaning and were usually cleaned every few weeks. Despite starting the cleaning process, the black substance and grease remained. The Administrator indicated that the black substance might be due to overuse and was not present when the ovens were new. She later presented a piece of the black substance, suggesting it could be removed, and mentioned that the cleaning schedule had been changed to weekly.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of fly activity in the kitchen on three different occasions. On 4/15/24, three flies were observed at the entrance to the drain in the middle of the kitchen, and on 4/16/24, flies were seen on an overhead light and flying around the steam table during lunch service. The Dietary Manager (DM) and Maintenance Director confirmed the presence of flies and indicated that the kitchen was sprayed monthly for pests. However, the insect light traps were found unplugged, and the Maintenance Director admitted that the traps frequently blew fuses and were knocked down by meal carts, leading to increased fly activity in the back service hall next to the kitchen. The Administrator also observed flies in the kitchen and acknowledged the difficulty in keeping the kitchen fly-free due to multiple doors and high traffic areas. Despite the facility's efforts to control the fly problem with pest control services, fly lights, and manual fly swatters, the issue persisted. The pest control company was called for additional service, and new fly light traps were installed, but these actions were taken after the surveyors' observations and interviews, highlighting the facility's initial failure to implement an effective pest control program to prevent reoccurring pest activity.
Failure to Include Resident in Care Planning Process
Penalty
Summary
The facility failed to invite Resident #84 to participate in the care planning process. Resident #84, who was cognitively intact, was admitted to the facility and had a care plan meeting scheduled with her Responsible Party (RP) on multiple occasions. However, there was no documentation indicating that Resident #84 was invited to attend these meetings or that the meetings took place. The care plan general notes and progress notes from 1/25/24 through 4/16/24 did not show any evidence of Resident #84's involvement in the care planning process. During an interview, Resident #84 confirmed that she had not been invited to any care plan meetings and expressed a desire to attend to discuss her goal of returning home. Interviews with Social Worker #1 and Social Worker #2 revealed a lack of communication and follow-through in ensuring Resident #84's participation in the care planning process. Social Worker #1 assumed that the care plan was reviewed with Resident #84 based on the notes from Social Worker #2 but did not confirm it. Social Worker #2 admitted to sending invitations to the RP but did not hold the care plan meeting or review the care plan with Resident #84. The Administrator confirmed that Social Worker #1 was responsible for ensuring Resident #84 was invited to the care plan meeting and that the meeting was held as required, but this did not occur.
Failure to Complete Timely MDS Significant Change Assessment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) significant change assessment within 14 days for a resident who was using a soft belt restraint. The resident, diagnosed with dementia, was admitted to the facility and evaluated for the use of a soft belt restraint to prevent injury due to high risk for falls and poor safety awareness. The physician ordered the restraint, and the care plan included specific instructions for its use. However, the MDS significant change assessment was completed late, beyond the required 14-day period. The MDS Nurse acknowledged the delay but could not provide a reason for it. The Administrator confirmed that the MDS Nurse was responsible for ensuring timely completion of the assessment.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of restraints. The resident, who was admitted with a diagnosis of dementia, had an active physician order for a soft belt restraint while up in a chair. The care plan and nursing progress notes confirmed the use of the soft belt restraint on multiple occasions. However, the MDS quarterly assessment did not reflect the use of this restraint. Interviews with the MDS Nurse and the MDS Nurse Consultant revealed that the normal process for coding the use of restraints involved observing the resident and reviewing nursing notes. The MDS Nurse Consultant admitted to missing the nursing notes that documented the restraint use, resulting in the inaccurate coding. The Administrator confirmed that the MDS Nurse Consultant was responsible for ensuring the accuracy of the MDS quarterly assessment.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for Resident #79, who was readmitted with a diagnosis of dysphagia. Despite the resident's claim and staff confirmation that he had signed a waiver to eat regular food and drink thin liquids, the medical record did not contain evidence of this signed waiver. Interviews with various staff members, including the Dietary Manager, Speech Language Pathologist/Rehab Director, Registered Dietitian, Director of Nursing, and Medical Director, confirmed that the waiver was signed and should have been uploaded to the resident's chart but was not found in the medical record. Resident #79 expressed his desire to consume regular food and thin liquids, and staff members were aware of his signed waiver. The waiver was intended to inform the resident of the risks associated with his dietary choices. Despite this, the waiver was not properly documented in the medical record, indicating a lapse in maintaining accurate and complete medical records as per professional standards. This deficiency was identified through staff interviews and record reviews conducted by the surveyors.
Failure in Infection Prevention and Control
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following the recertification and complaint investigation survey conducted on 2/4/22. This failure was evident in the area of infection prevention and control (F880), which was recited during the current recertification survey on 4/18/24. Specifically, the facility failed to handle visibly soiled and wet linen to avoid contamination of staff clothing, as observed with one laundry aide. Additionally, during the previous survey, a staff member was observed entering a quarantine room without wearing gloves and a gown, contrary to CDC guidelines for personal protective equipment (PPE). An interview with the Administrator and Director of Nursing revealed that although the QAA committee met monthly, there were no current monitoring plans in place for infection prevention and control, leading to the recited deficiency.
Failure to Properly Handle Soiled Linen
Penalty
Summary
The facility failed to handle visibly soiled and wet linen to avoid contamination of staff clothing. During an observation, a laundry aide was seen handling soiled and wet linen without wearing an apron or gown, which led to her uniform coming into contact with the contaminated laundry bin. The laundry aide only wore gloves and was not aware that additional PPE, such as a gown or apron, was required. The facility's policy stated that PPE, including an apron or gown, should be worn when handling soiled linen, but this was not followed or enforced in practice. Interviews with the laundry aide, housekeeping manager, and infection preventionist revealed a lack of consistent education and understanding regarding the proper use of PPE when handling soiled linen. The infection preventionist initially stated that only gloves were required but later clarified that gowns should also be used. The director of nursing and the administrator were also unaware of the specific PPE requirements, indicating a broader issue with policy communication and enforcement within the facility.
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What surveyors actually found near you
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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 Louisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Louisburg Healthcare & Rehabilitation Center | 1.7 mi | — | 0 | 0 |
| Hillside Nursing Center Of Wake Forest | 13.7 mi | — | 0 | 0 |
| Kerr Lake Nursing And Rehabilitation Center | 17.4 mi | — | 2 | 0 |
| Senior Citizens Home | 17.4 mi | — | 3 | 0 |
| Camellia Gardens Center For Nursing And Rehab | 18.3 mi | — | 7 | 1 |
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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 August 2026) and official state health department websites.