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.
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity JHarm
Care planningFalls
Isolated; immediate jeopardy to resident health or safety.Corrected 2025-05-09Record 345258-20260318-F689
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345258-20260318-F584
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345258-20260318-F677
F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-02Record 345258-20260318-F693
F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345258-20260318-F694
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345258-20260318-F695
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345258-20260318-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 EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 345258-20260318-F761
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 BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2026-03-31Record 345258-20260318-F585
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity CPaperwork
Dignity & rights
Widespread; potential for minimal harm.Corrected 2026-03-31Record 345258-20260318-F628
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2026-03-31Record 345258-20260318-F732
F760Ensure that residents are free from significant medication errors.Scope/severity JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-09-27Record 345258-20250116-F760
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F580
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F583
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F641
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F658
F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F661
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F695
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F756
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-04Record 345258-20250116-F757
F732Post nurse staffing information every day.Scope/severity BPaperwork
Staffing
Pattern; potential for minimal harm.Corrected 2025-02-04Record 345258-20250116-F732
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-26Record 345258-20231019-F550
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 345258-20231019-F602
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 345258-20231019-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 2023-09-13Record 345258-20231019-F689
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity GHarm
Dignity & rights
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-10-19Record 345258-20230810-F561
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 2023-10-19Record 345258-20230810-F697
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F580
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F582
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 2023-10-19Record 345258-20230810-F677
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F686
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 2023-06-15Record 345258-20230810-F689
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F755
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 2023-10-19Record 345258-20230810-F759
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F760
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 345258-20230810-F867
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F883
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-19Record 345258-20230810-F887
F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2023-10-19Record 345258-20230810-F625
F732Post nurse staffing information every day.Scope/severity BPaperwork
Staffing
Pattern; potential for minimal harm.Corrected 2023-10-19Record 345258-20230810-F732
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2023-10-19Record 345258-20230810-F842