Citations in North Carolina
Statistics, citations and compliance trends for long-term care facilities in North Carolina.
Statistics for North Carolina (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in North Carolina
Unsanitary conditions were observed in the walk-in cooler, walk-in freezer, and dry storage area. The cooler had debris on the floor, a dark brownish/grayish/blackish substance on the wall, shelving, and food containers, and water leaking from the ceiling fan due to condensation. The freezer had food debris and ice buildup on the floor and door threshold, and the dry storage area had fallen crackers, crumbs, and other debris. The Dietary Manager reported ongoing leaking and cleaning issues, while Maintenance and dietary leadership described inconsistent communication about the concerns.
MDS assessments were inaccurately coded for multiple residents in areas including ROM, dental status, PASRR, physical restraints, and active diagnoses. One resident with hemiplegia, hemiparesis, and contractures had a bed rail coded as a restraint instead of an enabler and did not have upper extremity impairment reflected; another resident who was edentulous was coded as having no dental issues; a resident with a Level II PASRR was coded incorrectly; another resident’s half-side rails were coded as restraints; and a resident with psychiatric diagnoses had schizophrenia omitted from the MDS.
Failure to obtain psychotropic medication consent before initiation or continuation of ordered meds affected three residents. One resident with anxiety and depression received buspirone and escitalopram, another resident with anxiety/depression received mirtazapine, and a third resident with major depression received sertraline; in each case, the MAR showed the meds were given as ordered, but the record lacked documentation that the resident or representative was informed in advance of the risks and benefits. The DON, Psychiatric NP, Medical Director, and Administrator stated consent was required for psychotropic meds, including when residents were admitted on them or when doses were increased.
Incomplete Abuse Investigation and Reporting: A cognitively intact resident reported that a nurse aide grabbed her and yanked off her gown, leaving bruising on her arms. The DON and nursing staff documented the allegation and substantiated abuse, but the investigation was limited to one hall and did not include a resident statement, a statement from the accused aide, or broader interviews and skin checks. The facility notified DHSR and law enforcement, but APS/DSS notification was not documented.
Failure to complete a comprehensive trauma screening assessment on admission for a resident with anxiety disorder and insomnia. The resident and RP reported a history of domestic violence, but the chart had no trauma screening or trauma-informed care plan. The DON said the trauma history was unknown because the assessment was never completed, and the Medical Director and former SW stated that trauma screening was not being done for new admissions.
Expired medications were found on the 100 Hall med cart during an observation with an RN present, including benzonatate, metoclopramide, and ondansetron past their expiration dates. The RN stated she was a PRN employee on her second shift and had only checked meds she administered, not the full cart. The Unit Coordinator and DON stated staff were instructed to inspect med carts routinely, and the DON said weekly and monthly inspections had been completed, including a pharmacy inspection that did not note expired meds.
Unsanitary Conditions in Kitchen Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the walk-in cooler, walk-in freezer, and dry storage area. During observation, the walk-in cooler contained six single-serve ice cream cups and used plastic cling wrap on the floor beneath a shelving unit, other unidentified debris, a dark brownish/grayish/blackish substance on the left wall and on several areas of the shelving unit, and a plastic container holding ketchup, mustard, syrup bottles, and liquid creamer that also had the same substance on the container and bottles. Water was observed leaking from the ceiling fan due to condensation that had accumulated along the vent rim. The Dietary Manager stated the ceiling fan ventilation seals had been leaking for 2-3 months and that Maintenance was aware. She reported that the issue had been repaired in March 2026 but began leaking again, and that the problem worsened during heavy rains. She also stated she had verbally informed the Maintenance Director for several months about the dark substance on the cooler wall during morning department head meetings and had reported the issue to the Director of Operations for dietary services, but could not recall exactly when she did so. The Maintenance Director later stated he was not aware of the dark substance until he was instructed to have dietary staff remove equipment and clean the cooler. The walk-in freezer had fallen food debris and unidentified debris beneath the bottom shelving units, ice accumulation on the floor beneath the shelving unit, and ice along the door threshold and lower edges of the door. The Dietary Manager stated there was no definitive cleaning schedule for the freezer and was not certain why ice had built up. In the dry storage area, a fallen package of crackers, crumbs, unidentified debris, and a fallen condiment package were observed beneath the shelving units, and the Dietary Manager stated there was no definitive cleaning schedule for that area. The Maintenance Director stated staff used maintenance clipboards to identify repair needs, but he seldom reviewed them unless informed of an important issue, and the Administrator stated she expected improved communication between the Dietary Manager and the Maintenance Director.
MDS Assessments Were Inaccurately Coded for Multiple Residents
Penalty
Summary
The facility failed to accurately code MDS assessments for residents in the areas of range of motion, dental status, PASRR, physical restraints, and active diagnoses. Record review and staff interviews showed that 5 of 36 reviewed assessments contained coding errors involving Residents #4, #13, #49, #50, and #59. Resident #4 had diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, and a left upper arm contracture. The care plan documented right-sided upper and lower extremity weakness, bilateral upper extremity contractures, and use of a right resting hand splint. A bed rail assessment identified a left side rail/assist bar as an enabler to promote independence, but the annual and quarterly MDS assessments coded the bed rail as a physical restraint and did not reflect impairment of the upper extremity. The MDS Coordinator stated the side rail was an enabler and should not have been coded as a restraint, and also stated the assessments should have reflected the upper extremity impairment. Resident #13’s dental record showed the resident was edentulous, but the annual MDS was coded as having no dental issues. Resident #49 had a Level II PASRR determination with no expiration date, yet the annual MDS stated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Resident #50’s bed rail assessment identified bilateral half-side rails as an enabler, but the quarterly MDS coded the bed rail as a physical restraint. Resident #59 had diagnoses including major depressive disorder and anxiety disorder, and a psychiatric note documented paranoid schizophrenia and depression, but the admission MDS did not code schizophrenia as an active diagnosis; the MDS Coordinator stated the resident had hallucinations and delusions and schizophrenia should have been coded.
Failure to Obtain Psychotropic Medication Consent
Penalty
Summary
The facility failed to obtain consent and inform residents or their resident representatives in advance of the risks and benefits of psychotropic medications before those medications were started or continued for three residents reviewed for unnecessary medications. Resident #43 had diagnoses including generalized anxiety disorder and major depressive disorder and was receiving buspirone and escitalopram; the record showed these medications were administered as ordered, but there was no information indicating the resident was informed in advance of the risks and benefits when admitted to the facility. The admission MDS indicated the resident was cognitively intact and had received an anti-anxiety medication and an antidepressant during the look-back period. Resident #4 had diagnoses including adjustment disorder with mixed anxiety and depressed mood and generalized anxiety disorder and was ordered mirtazapine for depression. The medical record contained no signed consent showing the resident was informed in advance of the risks and benefits of mirtazapine when admitted. The MAR showed the medication was administered as ordered, and the admission MDS indicated the resident was cognitively intact and received an antidepressant during the look-back period. Resident #16 had major depressive disorder and was ordered sertraline for depression. The record contained no information indicating the resident was informed in advance of the risks and benefits of sertraline. The MAR showed sertraline was administered as ordered, and the admission MDS indicated the resident was moderately cognitively impaired and received antidepressant medication during the look-back period. Staff, the Psychiatric NP, the Medical Director, the DON, and the Administrator all stated that psychotropic medication consent was required before initiation or dose increases, including for residents admitted on psychotropic medications, and the DON and Administrator stated the consent form had not been completed because the electronic form was not set up to automatically be completed on admission and was overlooked.
Incomplete Abuse Investigation and Reporting
Penalty
Summary
The facility failed to implement its abuse policy for investigation and reporting after an allegation of staff-to-resident abuse involving a cognitively intact resident admitted with anxiety disorder and insomnia. The resident reported that a nurse aide grabbed her and yanked her gown off, causing bruising to her arms. Bruising in various stages of healing was documented on both arms and the right hand, and the facility substantiated the allegation of abuse. The investigation was limited and did not include a written or signed statement from the resident or a written statement from the accused nurse aide. The nurse aide denied the allegation during a later telephone interview and stated he was never asked to complete a statement or interviewed by the facility, his agency, or law enforcement. The investigation also did not include documented interviews from other cognitively intact residents the nurse aide had worked with or skin assessments for all moderately and severely cognitively impaired residents in the facility; instead, the DON instructed staff to limit interviews and assessments to one hall. Reporting was also incomplete. The facility submitted the initial report to DHSR and notified law enforcement, but there was no documentation of notification to APS/DSS on the initial report. During interview, the DON stated she did not realize APS was supposed to be notified within 24 hours and acknowledged that a more thorough investigation could have been completed. The Administrator stated she would expect the DON to follow reporting regulations and complete a thorough investigation before substantiating the allegation.
Failure to Complete Trauma Screening on Admission
Penalty
Summary
The facility failed to complete a comprehensive trauma screening assessment for a newly admitted resident who had diagnoses including anxiety disorder and insomnia. Resident #58 was admitted with a cognitively intact MDS assessment, but the medical record contained no comprehensive trauma screening and no trauma-informed care plan. The resident’s Responsible Party stated that the resident had a history of domestic violence, and the resident also stated that she had a history of domestic violence and could not recall being asked questions about that history or any other evaluation for past trauma. The DON stated that a comprehensive trauma assessment should have been completed on all residents by the Social Worker upon admission and quarterly, and that any trauma history would have been care planned. The DON said Resident #58’s history of domestic violence was unknown because the assessment was never completed, and that the resident would have been care planned for no male caregivers had the history been known. The Medical Director stated that the Provider did not conduct any form of trauma screening on new admissions, and the previous facility Social Worker stated that she had not completed trauma screenings on newly admitted residents or as part of ongoing assessments. The Administrator stated that a comprehensive trauma assessment should have been completed by the Social Worker or designee on each resident to evaluate for trauma history and possible triggers.
Expired Medications Left on Medication Cart
Penalty
Summary
Expired medications were found on the 100 Hall medication cart during an observation with Nurse #1 present. The cart contained nine benzonatate 100 mg capsules with an expiration date of 6/8/2026, six metoclopramide 5 mg tablets with an expiration date of 5/18/2026, and sixteen ondansetron 4 mg tablets with an expiration date of 6/13/2026. Nurse #1 confirmed the expiration dates by reading the medication cards aloud. During interview, Nurse #1 stated she was a PRN employee working her second shift at the facility and said she had not checked the medication cart for expired medications that day, only the medications she administered. She stated medication carts should be checked weekly and that all medications on the cart, including PRN medications, should be within their expiration dates. The Unit Coordinator stated staff were instructed to inspect medication carts at the beginning and end of each shift, and the DON stated nurses and medication aides were educated to inspect medication carts daily and again prior to medication administration. The DON also stated Unit Coordinators conducted weekly medication cart inspections and pharmacy completed a monthly inspection on 6/26/2026 that documented no expired medications on the cart.
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Compliance trends in North Carolina
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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