Based on record review and staff interviews, the facility failed to implement their abuse policy for employees who worked in the capacity of a licensed nurse by not screening and verifying Employee #1's credentials prior to hiring her as a licensed nurse and allowing her to perform licensed nurse duties for which she had no documented education or nursing license. Employee #1 provided the facility nurse license information for an individual she found online with a name that was similar to her own and she worked at the facility in the role of a licensed nurse from 11/5/24 until her termination on 2/6/25. During this timeframe, Employee #1 had resident assignments and performed licensed nurse responsibilities that she was not qualified to provide. …
F607 citations in North Carolina
Abuse-prevention policies · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F607 more often than its own record predicts
1.97 times the share F607 takes of citations nationally.
Of every deficiency written in North Carolina in 2025, this is the portion that was F607.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F607 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 staff, the facility failed to implement their policy and procedure in the areas of protection, prevention and reporting abuse for 1 of 3 residents reviewed for abuse (Resident #1). NA # 2 witnessed NA # 1 strike a cognitively impaired resident (Resident #1) and did not effectively intervene or immediately report to nursing or administration; this resulted in NA # 2 striking the resident two more times. A reasonable person would expect a witness to remove a cognitively impaired, vulnerable resident from an abusive situation and protect them from further abuse. A reasonable person would feel very dehumanized and helpless from repeated physical abuse. Findings included:The facility's abuse policy dated 10/17/23 was reviewed. …
Based on record review and staff interviews, the facility failed to develop and implement an abuse policy consistent with the regulatory requirements, resulting in staff not adhering to the required reporting timeframes to the state agency, adult protective services, and the Administrator. This failure affected 1 of 1 resident reviewed for abuse (Resident #1).Findings included:The facility's policy titled, Abuse Prohibition last revised 11/2017, stated that all reports of alleged incidents of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of resident property must be reported to the Administrator immediately. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 1.49% | 2.00× |
| 2024 | 1.47% | 1.95× |
| 2025 | 1.30% | 1.97× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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