Based on record review, hospital staff, law enforcement, resident, and staff interviews, the facility failed to allow a resident to return to the facility after being sent to the hospital for an evaluation using the resident's behaviors prior to transfer as a basis for the decision for 1 of 3 residents reviewed for transfer and discharge (Resident #1). This resulted in Resident #1 being found in a ditch approximately six miles from the facility the day after the hospital discharge. …
F626 citations in North Carolina
Resident Rights Deficiencies
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F626 more often than its own record predicts
5.13 times the share F626 takes of citations nationally.
Of every deficiency written in North Carolina in 2025, this is the portion that was F626.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F626 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, Medical Director, Hospital Case Manager, Resident's Legal Guardian, and staff interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric evaluation. The resident remained in the hospital for over a month despite being cleared to return to the nursing home after 3 days. A reasonable person would expect once they were medically cleared from the hospital to be allowed back into their home and not being allowed back into their home could cause them to experience altered mental condition, fear, anxiety, and depressed mood. …
Based on record review and staff interviews the facility failed to allow a resident to return to the facility after hospitalization for 1 of 1 resident reviewed for hospitalization (Resident #70). Findings included: Resident #70 was admitted on [DATE]. Resident #70's admission Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact. His diagnoses included type 2 diabetes mellitus with foot ulcer and cellulitis of the right lower extremity. Resident #70 was transferred to the hospital for an acute condition on 1/3/25. Resident #70's hospital discharge summary dated 1/16/25 indicated the hospital case manager had noted [transferring facility name] had been Resident #70's long term care rehabilitation facility preference. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.24% | 2.03× |
| 2024 | 0.28% | 2.05× |
| 2025 | 0.29% | 5.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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