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
A resident with hemiplegia, hemiparesis, and vascular dementia was transferred in a mechanical lift from her room into a hallway to a reclining shower bed while only partially covered with a bath sheet, leaving her hips and buttocks exposed to others in the area. The resident said she did not like being left exposed, and staff stated the bed was usually placed outside her room because of space limits, though the DON expected her dignity to be preserved during the transfer.
A facility failed to plan group outings outside the facility for residents who said it was very important to them to go out in a group setting. Five cognitively intact residents on the Resident Council reported there had been no scheduled outings for over a year, and they described feeling sad, unhappy, lonely, or depressed because they could not go to restaurants, shop, socialize, or attend events like movies, bowling, Christmas lights, or parades. The AD and Administrator stated the facility had no van and relied on contract transport for medical appts only.
Medication error rate exceeded the 5% threshold when an RN administered two insulin doses to a resident with DM without priming the Lantus and NovoLog pens before each injection. Surveyors observed the RN give the ordered subcutaneous doses without completing the manufacturer-required safety test, and the RN stated she believed priming was only needed before first use. The DON and consultant pharmacist confirmed the pens should be primed before each dose.
Food items in the walk-in cooler were found with expired use-by dates, missing labels or dates, and signs of spoilage, including discolored lettuce and opened cheese products left improperly stored. Surveyors also observed pink and brown substances on the kitchen ice machine baffle above the ice trough. The Head [NAME] acknowledged the storage issues and that the ice machine needed cleaning, while the DDM and Administrator stated that food labeling, dating, spoilage checks, and ice machine sanitation were expected.
MDS assessments were inaccurately coded for falls and PASRR for multiple residents. One resident’s MDS did not fully reflect two documented falls, including one with a major injury, and several residents with documented Level II PASRR determinations were coded as not currently considered by the state PASRR process to have SMI/ID or a related condition. Staff interviews confirmed the chart contained the PASRR information, but the MDS entries did not match the record.
Missing Discharge Care Plan: A resident with OCPD and intact cognition did not have a discharge care plan despite care plan meetings discussing short-term stay, psychiatric services, and later transfer to a long-term psych facility. The comprehensive care plan had no discharge plan, and staff interviews showed confusion between the SW and MDS Coordinator about who was responsible for developing it.
Failure to Preserve Resident Dignity During Shower Transfer
Penalty
Summary
The facility failed to maintain Resident #67’s dignity during a shower transfer when two nurse aides moved her in a mechanical lift from her room into the common area hallway to a reclining shower bed on the other side of the hall. Resident #67 had diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, and vascular dementia. Her quarterly MDS indicated she was severely cognitively impaired, required a wheelchair for mobility, was dependent on staff for transfers, dressing, and bathing, and had a care plan that included assistance with positioning, transfers, toileting, personal hygiene, and bathing as needed. During continuous observation, NA #1 and NA #2 transferred Resident #67 with a bath sheet covering the front of her nude body, but her bare hips and the bare sides of her buttocks were exposed while she was moved through the hallway. Other staff members and residents were present in the hallway during the transfer. Resident #67 later stated that the nurse aides would cover the front part of her body with a sheet and leave her sides exposed, and that she really did not like that. Her care plan also addressed behavioral symptoms, including undressing with the door open, refusing care, crying, and cursing, and included providing an appropriate level of privacy. The nurse aides stated they usually placed the reclining shower bed right outside Resident #67’s room because there was not enough room to place both the mechanical lift and the bed inside the room. NA #1 said the bed had been moved across the hall on the observed occasion and that they typically would not push the lift across the hall. NA #2 stated her normal process was to undress Resident #67 in bed and cover her with a shower sheet before transfer, and she did not realize Resident #67 was exposed. The DON later observed that the mechanical lift fit between the beds in the room, but the reclining shower bed barely fit at the foot of the bed and could not safely be used inside the room due to space constraints. The DON and Administrator stated they expected staff to preserve Resident #67’s dignity and ask about her shower preference.
No Scheduled Outings for Residents Who Wanted Group Activities Outside the Facility
Penalty
Summary
The facility failed to ensure group activities were planned outside of the facility for residents who stated that going out in a group setting was very important to them. Review of the July 2025 through July 2026 activity calendars showed activities inside the facility during the week and on weekends, but no activities scheduled outside of the facility. Observation on 7/13/26 showed the facility was in a rural area within 10 to 15 minutes of local and commercial shops, grocery stores, fast food, and sit-down restaurants. Five residents reviewed for activities—Resident #32, #34, #58, #63, and #66—each had MDS assessments indicating it was very important to have activities that included going outside of the facility and doing things in a group setting, and each was cognitively intact. During the Resident Council meeting on 7/14/26, these residents stated there had been no scheduled group activities outside of the facility since they were admitted or for over a year. They reported that not being able to leave the facility made them feel sad, unhappy, lonely, or depressed, and they described wanting to go to restaurants, shop for personal items, socialize with people outside the facility, go bowling or to the movies, and see Christmas lights or Christmas parades. The Activity Director stated she had worked at the facility for 4 years and had not been able to schedule resident group activities outside of the facility because the facility did not have its own van and contract transportation was used for medical appointments only. She said she had brought the issue to Administration and understood they were trying to work on a transportation solution. The Administrator stated there had been no scheduled activities outside of the facility since he became Administrator over 3 years earlier, and he confirmed the facility did not have its own van and relied on contract transportation for medical appointments.
Medication Error Rate Exceeded Due to Unprimed Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% after surveyors identified 2 medication errors out of 30 opportunities, resulting in a 6.67% medication error rate for 1 of 3 residents observed during medication pass. The errors involved incorrect administration of insulin pens for a resident with type 2 diabetes mellitus without complications who had orders for Lantus Solostar U-100 insulin 13 units subcutaneous each morning and NovoLog FlexPen U-100 insulin 8 units before meals. During a continuous medication pass observation, Nurse #1 prepared the resident’s Lantus and NovoLog insulin pens and administered both subcutaneous doses without priming either pen as required by the manufacturer instructions. The instructions for both insulin pens stated that a safety test/priming step should be completed prior to each injection to ensure insulin comes out of the needle. In interview, Nurse #1 stated she did not know the pens should be primed before each dose and believed priming was only needed before first use. The Consultant Pharmacist stated the manufacturer instructions required priming before each dose, and the DON stated the pens should be primed prior to each dose to ensure the correct dose was administered.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
Food was found stored in the walk-in cooler with multiple labeling and dating problems and several items showing signs of spoilage. During an observation with the Head [NAME], surveyors found containers of tuna, tomato soup, alfredo, brown gravy, cheezy rice, and egg salad with use-by dates that had passed, a metal steam pan with no label or date that appeared to contain grated cheese over pasta with a white creamy sauce, chicken noodle soup with no date, opened mozzarella cheese with no date, and an opened package of sliced American cheese left open to the air with no opened-on or use-by date. Two sealed bags of lettuce were also observed with brown discoloration and brown liquid in the bottom of the bags. Surveyors also observed the kitchen ice machine with pink and brown substances scattered across the entire baffle directly above the full trough of ice. During the observation, the Head [NAME] stated he understood that items were not stored correctly and that the ice machine needed to be cleaned. The District Dietary Manager stated that it was the Head Cook's or Food Service Manager's responsibility to ensure food was labeled and dated, that stored food should be checked daily for proper labeling and signs of spoilage, and that the ice machine should be wiped down daily with a monthly deep clean by maintenance. The Administrator stated that all food was expected to be labeled, dated, and stored correctly, spoiled items discarded immediately, and the ice machine maintained and sanitized properly.
MDS Assessments Incorrectly Coded for Falls and PASRR
Penalty
Summary
The facility failed to accurately code MDS assessments in the areas of falls and PASRR for 7 of 22 residents reviewed for MDS accuracy. The record review and staff interviews showed that several MDS assessments completed by a traveling MDS Coordinator did not match information documented in the residents’ medical records, including fall events and Level II PASRR determinations. For one resident admitted with chronic respiratory failure with hypoxia and a healing left humerus fracture, the admission MDS coded a fall in the last month and a fracture related to a fall prior to admission. However, nurse progress notes documented two separate falls after admission: one in which the resident rolled out of bed and landed on her buttocks, and another in which the resident was found on the floor next to the bed with right hip pain and was sent to the ER. Hospital records showed an acute comminuted impacted right intertrochanteric fracture, and the discharge MDS coded only one fall with major injury. The MDS Coordinator later stated the resident had two falls since the prior assessment and that the discharge MDS should have reflected one fall with no injury and one fall with major injury. For six residents, the MDS assessments did not accurately reflect existing Level II PASRR determinations. The records showed Level II PASRR notification letters for residents with diagnoses including anxiety disorder, bipolar disorder, unspecified dementia with psychotic disturbances, schizoaffective disorder, major depressive disorder, and other psychiatric conditions. The annual, significant change, or admission MDS assessments for these residents stated they were not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, despite documentation in the chart showing active PASRR determinations. Staff interviews confirmed the PASRR letters were in the EMR and that the MDS Coordinator was responsible for coding PASRR, but the assessments were still coded without the Level II PASRR information.
Missing Discharge Care Plan
Penalty
Summary
The facility failed to develop a discharge care plan for Resident #83, who was admitted with obsessive-compulsive personality disorder (OCPD). A care plan meeting on 12/01/25 documented that the resident did not wish to attend and that the interdisciplinary team, including the Business Office Manager, Social Worker, DON, and Administrator, discussed that she would remain at the facility short-term, receive psychiatric services before discharging home, and had no barriers to discharge. The admission MDS assessment noted the resident had intact cognition, her overall goal was to discharge to the community, there was no active discharge planning in place, and she did not want to be asked about returning to the community on all MDS assessments. A later care plan meeting on 01/21/26 documented that the resident again did not attend and that her recent inpatient psychiatric admission was discussed, with Family Member #1 stating they now wanted her transferred to a long-term psychiatric facility for treatment. Review of the comprehensive care plan, last revised on 03/03/26, showed no discharge care plan. The discharge-return not anticipated MDS indicated the resident discharged to an inpatient psychiatric facility. During interviews, the SW stated discharge planning begins on admission and that the MDS Coordinator was typically responsible for the discharge care plan, while the MDS Coordinator said there was confusion about whether the MDS Coordinator or SW was responsible and confirmed the resident did not have a discharge care plan. The Administrator stated a discharge care plan should be part of the comprehensive care plan and that the SW was responsible for starting discharge planning on admission and documenting updates as needs or goals changed.
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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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