Based on record review, resident and staff interviews, the facility failed to accurately code current tobacco use on the Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accuracy of assessments (Resident #38).The findings included:Resident #38 was admitted to the facility on [DATE].Resident #38's care plan revised on 7/14/2026 had a focus area for utilizing a vape and cigarettes. Interventions included Resident #38 would adhere to the tobacco/smoking policies of the facility, the facility would conduct a smoking safety evaluation on admission and as needed, educate resident/responsible party (RP) on the facility's tobacco/smoking policies, ensure vape was charged, provide smoking apron if Resident #38 choose to smoke a cigarette and Resident #38 required supervision with… …
F641 citations in North Carolina
Accuracy of assessments · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F641 more often than its own record predicts
2.48 times the share F641 takes of citations nationally.
Of every deficiency written in North Carolina in 2025, this is the portion that was F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F641 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 staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of use of a wander/elopement alarm (Resident #11) and the use of anticoagulant medication (Resident #10) for 2 of 25 residents whose MDS assessments were reviewed. The findings included: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses which included hypertension. A physician order dated 2/20/26 for clopidogrel (an antiplatelet medication) 75 milligram (mg) give one tablet by mouth daily was observed in Resident #10's record. No anticoagulant medication had been ordered. Review of the Medication Administration Record (MAR) for February 2026 revealed Resident #10 received clopidogrel 75 mg daily as ordered. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 4.76% | 2.79× |
| 2024 | 3.50% | 2.08× |
| 2025 | 4.57% | 2.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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