Based on staff interviews, phlebotomist and physician interviews and record review the facility failed to honor a resident's refusal to have her blood draw when a contract phlebotomist held a resident's arm down and forced the resident against her will to have blood drawn for 1 of 3 sampled residents for resident rights (Resident #3). Immediate Jeopardy began on [DATE] when phlebotomist #1 held the resident's arm with force to obtain Resident #3's blood specimen against her will. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of compliance. …
F550 citations in North Carolina
Resident rights and dignity · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F550 less often than its own record predicts
0.84 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina in 2025, this is the portion that was F550.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F550 findings written in North Carolina, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review and interviews with resident, family, Medical Director, and staff, the facility failed to treat a resident in a dignified manner when staff filed legal guardianship of the resident without communicating with the resident or the resident's family and without having the resident evaluated or assessed to be deemed incompetent. Resident #1, with visible tears in her eyes, stated she felt the facility was trying to control her and take her rights away. This affected 1 of 1 resident reviewed for dignity and respect (Resident #1). …
Based on record review, staff interviews, and Responsible Party interview, the facility failed to treat a resident in a dignified manner when Resident #1, a resident with severe cognitive impairment, was yelling out and Nurse Aide #1 loosely placed her hand over the resident's mouth and yelled at the resident to shut up in an effort to quiet the resident. The reasonable person concept was applied, as a reasonable person would expect to receive care without being yelled at. This deficient practice affected 1 of 3 residents reviewed for dignity (Resident #1).Findings included:Resident #1 was readmitted to the facility on [DATE] with diagnoses including vascular dementia, anxiety disorder, and depression.An annual Minimum Data Set assessment dated [DATE] documented Resident #1 as having… …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 2.40% | 1.17× |
| 2024 | 1.71% | 0.78× |
| 2025 | 1.78% | 0.84× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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