Based on record review and interviews with staff, paramedic and family, the facility failed to provide an accurate code status to Emergency Medical Services (EMS) for one of three residents reviewed for advanced directives. Resident #1, who chose a full code status, experienced [CONDITION(S)] on [DATE] and was not provided cardio-pulmonary resuscitation (CPR). Resident #1 expired at the facility on [DATE] and the certificate of death indicated a cause of death included cardiorespiratory arrest. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated [DATE] and completed by Nurse #1 revealed Resident #1 complained of chest pain to Nurse #1. …
F578 citations in North Carolina
Advance directives · Resident Rights Deficiencies
Honor 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.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F578 more often than its own record predicts
1.83 times the share F578 takes of citations nationally.
Of every deficiency written in North Carolina in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F578 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, staff, resident and law enforcement interviews, the facility failed to honor a resident's right to refuse treatment when the resident declined five hemodialysis (a life-sustaining procedure for kidney failure that uses a machine to filter waste, toxins, and excess fluids from the blood) treatments and the facility proceeded to file an involuntary commitment which deemed the resident a danger to herself. The resident reported once the local law enforcement officer had walked her out to the front entrance of the facility, the resident was asked to put her hands out and the officer placed handcuffs on both wrists in the front of her body and had her sit in the backseat of the police car. …
Based on record review, resident, resident representative, and staff interviews, the facility failed to document and provide written information to residents/representatives regarding their right to refuse medical/surgical treatment or to formulate an advance directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) for 13 of 14 residents reviewed for advance directives (Residents #1, #2, #4, #6, #7, #8, #10, #11, #13, #25, #43, #80, and #85). Findings included: a. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 1.25% | 1.17× |
| 2024 | 1.71% | 1.74× |
| 2025 | 1.73% | 1.83× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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