Based on record review, police, Emergency Medical Technicians (EMTs), resident, and staff interviews, the facility failed to provide Activities of Daily Living (ADL) Care, including incontinence care. The failure occurred on 1/16/22 during a period when there was just one Licensed Practical Nurse (LPN) and two Nursing Assistants in the facility to provide care for 98 residents. Two interviewed residents (Resident #7 and Resident #11) stated they did not receive incontinent care for an extended period of time and Resident #11 stated she had physical discomfort from having had to wait an extended period of time for incontinent care. Interviews with first responders who arrived at the facility described multiple residents in need of care and a strong smell of urine and feces in the facility. …
F677 citations in North Carolina
ADL care for dependent residents · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F677 less often than its own record predicts
0.57 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina in 2025, this is the portion that was F677.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F677 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 observations, record review, and resident and staff interview the facility failed to provide incontinence care when requested for 2 of 3 residents reviewed for activities of daily living care (Resident #53 and Resident #80). Resident #53 was noted to have a new open area to the right buttocks when incontinence care was provided, and Resident #53 reported the area was sore. Findings included: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses of hip fracture and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #53 was cognitively intact, required extensive assistance with toileting, and was always incontinent of bladder and bowel. No refusal of care was noted during the assessment reference period. …
Based on record review and resident and staff interviews, the facility failed to provide bathing, including the resident's designated shower, on the assigned shower day. This deficient practice affected 1 of 3 residents reviewed for activities of daily living (ADL) care (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF). The care plan initiated on 11/13/25 noted Resident #29 had an ADL self-care performance deficit related to a recent hospitalization.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was cognitively intact and had no behaviors or rejection of care. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 3.27% | 1.18× |
| 2024 | 2.43% | 1.00× |
| 2025 | 1.30% | 0.57× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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