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.
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 345262-20250605-F641
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 345262-20250605-F679
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 345262-20250605-F727
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 2025-07-01Record 345262-20250605-F755
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 345262-20250605-F838
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-07-01Record 345262-20250605-F925
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 2025-07-01Record 345262-20250605-F628
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2025-07-01Record 345262-20250605-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 2024-06-09Record 345262-20240516-F600
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 2024-06-09Record 345262-20240516-F677
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-09Record 345262-20240516-F685
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 2024-06-09Record 345262-20240516-F695
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-09Record 345262-20240516-F727
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 2024-06-09Record 345262-20240516-F761
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-09Record 345262-20240516-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 2024-06-09Record 345262-20240516-F880
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity BPaperwork
Dignity & rights
Pattern; potential for minimal harm.Corrected 2024-06-09Record 345262-20240516-F623
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2024-06-09Record 345262-20240516-F657
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2024-06-09Record 345262-20240516-F732
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-02-22Record 345262-20230131-F686
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity HHarm
Care planning
Pattern; actual harm that is not immediate jeopardy.Corrected 2023-02-22Record 345262-20230131-F697
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity HHarm
Medication
Pattern; actual harm that is not immediate jeopardy.Corrected 2023-02-22Record 345262-20230131-F755
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 2023-02-22Record 345262-20230131-F561
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-22Record 345262-20230131-F578
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 2023-02-22Record 345262-20230131-F584
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-22Record 345262-20230131-F657
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 2023-02-22Record 345262-20230131-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 2023-02-22Record 345262-20230131-F690
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 2023-02-22Record 345262-20230131-F695
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-02-22Record 345262-20230131-F726
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-02-22Record 345262-20230131-F727
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 2023-02-22Record 345262-20230131-F761
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 2023-02-22Record 345262-20230131-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 2023-02-22Record 345262-20230131-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 2023-02-22Record 345262-20230131-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 2023-02-22Record 345262-20230131-F887
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-02-22Record 345262-20230131-F947
F680Ensure the activities program is directed by a qualified professional.Scope/severity CPaperwork
Care planning
Widespread; potential for minimal harm.Corrected 2023-02-22Record 345262-20230131-F680
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2023-02-22Record 345262-20230131-F732