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.
F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-03Record 345566-20250512-F553
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 2025-06-13Record 345566-20250512-F580
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-13Record 345566-20250512-F658
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 2025-06-13Record 345566-20250512-F725
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-13Record 345566-20250512-F760
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity HHarm
Dignity & rights
Pattern; actual harm that is not immediate jeopardy.Corrected 2024-03-11Record 345566-20240216-F550
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-03-11Record 345566-20240216-F689
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 HHarm
Staffing
Pattern; actual harm that is not immediate jeopardy.Corrected 2024-03-11Record 345566-20240216-F725
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-11Record 345566-20240216-F554
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 2024-03-11Record 345566-20240216-F657
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 2024-03-11Record 345566-20240216-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-30Record 345566-20240216-F684
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 2024-03-11Record 345566-20240216-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 2024-03-11Record 345566-20240216-F695
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 2024-03-11Record 345566-20240216-F761
F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-11Record 345566-20240216-F777
F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-03-11Record 345566-20240216-F802
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 2024-03-11Record 345566-20240216-F842
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 2024-03-11Record 345566-20240216-F867
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-11Record 345566-20240216-F883
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 2024-03-11Record 345566-20240216-F947
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 2024-03-11Record 345566-20240216-F623
F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2024-03-11Record 345566-20240216-F640
F565Honor the resident's right to organize and participate in resident/family groups in the facility.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-07-28Record 345566-20220630-F565
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 2022-07-28Record 345566-20220630-F578
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-07-28Record 345566-20220630-F758
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-07-28Record 345566-20220630-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 2022-07-28Record 345566-20220630-F887
F732Post nurse staffing information every day.Scope/severity BPaperwork
Staffing
Pattern; potential for minimal harm.Corrected 2022-07-28Record 345566-20220630-F732