Based on record reviews and staff interviews, the facility failed to implement their Admissions Policy and Procedure and verify the identity of a cognitively impaired resident when he was admitted to the facility with paperwork from the discharging skilled nursing facility for Person #2 (potential new admission with same first and last name as Resident #1). As a result, Resident #1, who did not have a diagnosis of diabetes, was administered 3 doses of long-acting insulin, and experienced 3 three low blood sugar levels before the insulin was discontinued. In addition, Resident #1 received an anticoagulant, aspirin, a diuretic, and a medication used to treat hypothyroidism from 07/17/23 until 09/15/23 prescribed for Person #2. …
F620 citations in North Carolina
Resident Rights Deficiencies
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
North Carolina cites F620 more often than its own record predicts
2.60 times the share F620 takes of citations nationally.
Of every deficiency written in North Carolina in 2023, this is the portion that was F620.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F620 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, family and staff interviews the facility failed to include the resident representative identified in the admission agreement in the decision to transport a resident with moderately impaired cognition to the bank to withdraw money to pay his facility bill (Resident #107). Findings Included: Resident #107 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the minimum data sets ((MDS) dated [DATE], 7/7/18 and 4/3/18 for Resident #107 revealed his cognition was moderately impaired. A phone interview on 1/30/19 at 10:04 am with the resident representative (RR) for Resident #107 revealed she was the residents responsible party and power of attorney (POA). …
What else North Carolina surveyors cite →
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