CMS · North Carolina Division of Health Service Regulation publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F552Ensure that residents are fully informed and understand their health status, care and treatments.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 345191-20250611-F552
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 345191-20250611-F605
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 345191-20250611-F641
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 345191-20250611-F689
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-14Record 345191-20250611-F759
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity GHarm
Dignity & rights
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-04-24Record 345191-20240327-F550
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity KHarm
Dignity & rights
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F585
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F602
F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F603
F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F604
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity KHarm
Abuse & neglect
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F607
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F697
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity KHarm
Medication
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F755
F880Provide and implement an infection prevention and control program.Scope/severity KHarm
Infection control
Pattern; immediate jeopardy to resident health or safety.Corrected 2024-04-24Record 345191-20240327-F880
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F561
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F600
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F677
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F692
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F725
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F760
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F761
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F842
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-04-24Record 345191-20240327-F867
F641Ensure each resident receives an accurate assessment.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2024-04-24Record 345191-20240327-F641
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2024-04-24Record 345191-20240327-F732
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-26Record 345191-20221201-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-26Record 345191-20221201-F607
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-26Record 345191-20221201-F641
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-26Record 345191-20221201-F692
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-12-26Record 345191-20221201-F725
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-26Record 345191-20221201-F755
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-12-26Record 345191-20221201-F760