Based on observation, record review, and staff, Legal Guardian, and former facility Executive Director interviews, the facility failed to exercise the rights of the Resident's Representative when Resident #115 had unsupervised visits with her son despite restricted visitation instructions from the Legal Guardian. The Legal Guardian stated, on Friday 1/24/2025, she informed the Admission's Director and the Resident Concierge Resident #115 was not to have visits from her son without supervision. Resident #115 was cognitively impaired, was adjudicated incompetent, and had history of sexual interactions with her son that included sexual intercourse, open mouth kissing, and inappropriate touching as witnessed by the previous facility's Executive Director. …
F551 citations in North Carolina
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F551 more often than its own record predicts
2.48 times the share F551 takes of citations nationally.
Of every deficiency written in North Carolina in 2025, this is the portion that was F551.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F551 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 Legal Guardian, and staff interviews, the facility failed to communicate with the Resident's Legal Guardian regarding resident's abdominal pain and the resident's refusal to go to the hospital. This occurred for 1 of 3 sampled residents reviewed for the surrogate to exercise the resident's rights (Resident #1). Findings included: Resident #1 was admitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, diabetes mellitus type (2), dementia, and hypomagnesemia (a condition characterized by abnormally low levels of magnesium in the blood. …
Based on record review, and interviews with the Health Care Power of Attorney (HCPOA), the Resident Representative, staff, and the Medical Director, the facility failed to honor an immunization declination when Resident #376 was administered an influenza vaccine after her HCPOA had declined the vaccination. This was for 1 of 6 residents reviewed for vaccination status (Resident #376). The findings included: Resident #376 was admitted to the facility on [DATE]. Review of Resident #376's medical record revealed The Statutory Form Health Care Power of Attorney dated 3/2/21. The form indicated Resident #376 appointed her Health Care Power of Attorney (HCPOA) to act for her and in her name to make health care decisions for her. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.05% | 0.89× |
| 2024 | 0.08% | 1.04× |
| 2025 | 0.19% | 2.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction