Based on observation, record review, video review, physician, physician assistant and staff interviews the facility failed to protect Resident #98 and Resident #305 from involuntary seclusion when Medication Aide #1 and Nurse Aide (NA) #2 placed the residents in an activity/dining room in the evening with the doors closed, dim lighting, and no supervision due to the residents' yelling/screaming behaviors. The residents were unable to exit the room without assistance. Residents #98 and #305 were diagnosed with dementia and were at risk for falls. The reasonable person concept was applied for this deficient practice in that a reasonable person would have experienced feelings of fear and isolation from being confined to a room with no ability to exit. …
F603 citations in North Carolina
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
North Carolina cites F603 more often than its own record predicts
1.56 times the share F603 takes of citations nationally.
Of every deficiency written in North Carolina in 2024, this is the portion that was F603.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F603 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 residents, staff, and physician, the facility failed to protect residents' rights to be free from involuntary seclusion for 1 of 3 resident (Resident #1) reviewed for abuse. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised in August 2024, revealed in part the facility would ensure all residents to remain free from involuntary seclusion. Resident #1 was admitted to the facility on [DATE]. The diagnoses included vascular dementia, cerebral vascular accident, restless leg syndrome and atrial fibrillation. The significant change Minimum Data Set(MDS) dated [DATE] indicated Resident #1's cognition was severely impaired. Resident's #1's mode of transportation was the wheelchair. …
What else North Carolina surveyors cite →
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