Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Presidential Oaks during CMS and state inspections, most recent first.
A resident sustained a spiral fracture of the left tibia, and the facility did not conduct a thorough investigation as required by its policy. The DON did not interview LNAs who had cared for the resident prior to the injury, and key staff were not asked to provide statements, resulting in the cause of the injury remaining unidentified.
A resident assessed as dependent for transfers and requiring a mechanical lift was repeatedly transferred by staff using unsafe manual techniques, despite clear recommendations from PT and an updated care plan. The resident expressed pain during these transfers and was later found to have a spiral fracture of the lower leg.
The facility failed to store food properly, as observed in the kitchen. An open, undated bag of frozen rib patties was found in the walk-in freezer, and a box of tomatoes with black spots and moldy pepper jack cheese were found in the refrigerator. These issues were confirmed by the Chef Manager and Assistant Chef Manager, violating the FDA 2022 Food Code requirements for food storage.
The facility failed to provide written notice of transfer or discharge for four residents who were hospitalized. A resident was transferred to the hospital without documentation of a notice of transfer, and staff admitted that no notice was provided due to the short duration of the hospital stay. Another resident was transferred without a written notice, and staff confirmed that notices are only faxed to the LTC Ombudsman. Additionally, a resident with a power of attorney for healthcare was sent to the hospital multiple times without receiving a written notice of transfer discharge.
The facility failed to notify residents or their representatives of the bed hold policy before hospital transfers. Four residents were transferred without receiving the required notification, as confirmed by staff interviews and record reviews. The facility's policy mandates that social workers or designees discuss bed hold options, but this was not adhered to.
Failure to Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged violation involving a resident who sustained a spiral fracture of the left tibia. Nursing progress notes indicated that the resident was found with pain, swelling, and redness in the left lower extremity, which was later diagnosed as a minimally displaced spiral oblique fracture. The injury was considered of unknown source, as the cause could not be explained by the resident and was not observed by staff. Despite the seriousness of the injury, the facility did not follow its own policy requiring a comprehensive investigation of such incidents. Interviews revealed that the Director of Nursing did not interview any Licensed Nursing Assistants (LNAs) who had cared for the resident on the days leading up to the discovery of the injury. One LNA reported that the resident had expressed pain during a transfer and had been kept in bed due to leg pain, but was not interviewed or asked to provide a statement regarding the injury. The facility's policy mandates that all nursing department witnesses and suspects be interviewed and their statements recorded, but this was not done, and the cause of the fracture was not identified.
Failure to Implement Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to implement appropriate transfer interventions for a resident who was assessed as requiring a mechanical lift (hoyer) with two staff for transfers. Despite repeated recommendations and notifications from physical therapy staff, including documentation on multiple occasions that the resident was dependent for transfers and unable to bear weight through the lower extremities, nursing staff continued to use unsafe transfer techniques such as a one-person stand-pivot and bear hugging. These methods were explicitly identified as unsafe for both the resident and staff, and the need for a mechanical lift was communicated verbally and in writing to nursing staff and the unit manager. On one occasion, a licensed nursing assistant transferred the resident using a stand-pivot technique, during which the resident expressed pain. The following day, the resident was kept in bed due to complaints of pain and was observed holding their left leg. Subsequent nursing assessment revealed swelling, redness, and tenderness in the left lower extremity, and an x-ray confirmed a minimally displaced spiral fracture of the mid to distal tibia. The resident's care plan had been updated to require a two-person hoyer transfer, but this intervention was not followed, resulting in injury.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage in accordance with professional standards for food service safety. During an observation in the kitchen, surveyors found an open and undated bag of frozen rib patties in the walk-in freezer. Additionally, in the walk-in refrigerator, a box of tomatoes with visible black spots and a bag of cubed moldy pepper jack cheese were discovered. These findings were confirmed through an interview with the Chef Manager and Assistant Chef Manager. The review of the FDA 2022 Food Code highlighted the requirement for food to be stored in packages, covered containers, or wrappings to prevent contamination, and to be kept in a clean, dry location away from potential contaminants.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide written notice of transfer or discharge for four residents who were hospitalized. Resident #48 was transferred to the hospital on 10/27/24, but no documentation of a notice of transfer was found in the medical record. Staff E from Social Services admitted that no notice was provided because the hospital stay was less than 24 hours. Similarly, Resident #6 was transferred to the hospital on 10/20/24, and there was no written notice of transfer and discharge in the medical record. Staff A, a social worker, confirmed that the facility only faxes notices to the Office of Long Term Care Ombudsman and does not provide them to the resident or their representative. Resident #64 was transferred to the hospital on 9/10/24 for a scheduled procedure, but no written notice of transfer and discharge was documented. Staff A confirmed that the facility does not provide such notices to residents or their representatives. Additionally, Resident #16, who had an activated power of attorney for healthcare, was sent to the hospital on multiple occasions without receiving a written notice of transfer discharge. Staff A confirmed that the facility does not provide written notices of transfer discharge to residents or their representatives.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed hold policy prior to transferring them to a hospital, as required. This deficiency was identified during a review of the medical records of four residents who had been hospitalized. For Resident #48, there was no evidence in the medical record that the bed hold policy was communicated upon their discharge to the hospital. Staff E from Social Services confirmed this oversight during an interview. Similarly, Resident #16's records showed multiple hospital transfers without any documentation of bed hold policy notification, which was corroborated by Staff A from Social Services, who admitted that such notifications were not being made. Resident #6 was transferred to the hospital after an incident where they were found on the floor, yet there was no documentation of a bed hold notice being provided. Staff H from the Business Office and Staff D, the Administrator, confirmed that bed hold notices were not routinely provided at each transfer. Additionally, Resident #64 was transferred for a scheduled procedure without any record of a bed hold notice being given. The facility's policy, as reviewed, stated that the social worker or designee should contact the resident or representative to discuss bed hold options, but this was not followed in these cases.
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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 Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Center | 0.4 mi | — | 9 | 0 |
| Harris Hill Center, Genesis Healthcare | 1.2 mi | — | 0 | 0 |
| Havenwood-heritage Heights | 2.5 mi | — | 0 | 0 |
| Epsom Healthcare Center | 10 mi | — | 11 | 0 |
| Hackett Hill Healthcare Center | 11.6 mi | — | 2 | 0 |
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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.