F628 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F628 more often than its own record predicts
Versus expected share1.03×
1.03 times the share F628 takes of citations nationally.
Share of North Carolina citations0.96%
Of every deficiency written in North Carolina in 2025, this is the portion that was F628.
North Carolina0.96%
National0.93%
Share of all citations that were F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F628 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.
J · Immediate jeopardy, isolatedAugust 25, 2025
Based on record reviews, and Responsible Person and staff interviews, the facility failed to ensure a resident's Do Not Resuscitate (DNR) goldenrod form (a portable physician's order printed on goldenrod colored paper that communicates an individual's wishes regarding resuscitation efforts for emergency responders) and Medical Orders for Scope of Treatment (MOST) form (outlines health care and end-of-life care instructions) stating DNR and Do Not Intubate (DNI) (intubation is a medical procedure where a tube is inserted into the airway to support breathing) were provided to Emergency Medical Services (EMS) upon emergent transfer to the hospital on Sunday 6/22/25. …
D · No harm, potential for more than minimal, isolatedAugust 6, 2026
Based on record reviews, interviews, and review of the facility policy titled TCC [Tsali Care Center] Social Services-Transfers and Discharge Policy, the facility failed to ensure pertinent health information was provided to the hospital upon transfer of one (1) resident (Resident #7); failed to provide written notice of transfer to the resident for one (1) resident (Resident #7); and failed to notify the Ombudsman of a discharge for one (1) resident (Resident #99) of six (6) residents reviewed.
The findings include:
1. Resident #7 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, urinary tract infection, resistance to multiple antimicrobial drugs, stage 4 pressure ulcer of sacral wound region, and neuromuscular dysfunction of bladder. …
B · No harm, potential for minimal, patternJuly 30, 2026
Based on record reviews and staff interviews, the facility failed to notify the resident and resident's representative (RR) in writing of the reason for the transfer/discharge to the hospital and failed to send a copy of the discharge notice to the Ombudsman for 4 of 5 residents. (Resident #57, Resident #24, Resident #2, and Resident #8) The facility also failed to notify the resident and/or Resident's Representative of the facility policy for bed hold for 1 of 5 residents reviewed for hospitalization. (Resident #8) The findings included:1.Resident #57 was admitted to the facility 3/28/25.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had moderately impaired cognitive skills for daily decision. He exhibited inattention and alerted level of consciousness. …
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