F684 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F684 less often than its own record predicts
Versus expected share0.71×
0.71 times the national share — cited less often here than elsewhere.
Share of North Carolina citations3.03%
Of every deficiency written in North Carolina in 2025, this is the portion that was F684.
North Carolina3.03%
National4.30%
Share of all citations that were F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F684 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, 2026
Based on observations, record review, review of recorded transcripts, and interviews with staff, Responsible Party (RP), Nurse Practitioner, and Medical Director, the facility failed to recognize the seriousness of an unwitnessed fall with a head injury for a resident that was prescribed an antiplatelet medication daily which can cause an increased bleeding risk or identify the urgent need for medical attention. On 09/14/25 at 1:07 AM, Resident #116 experienced an unwitnessed fall in his room while attempting to adjust his packaged terminal air conditioner (PTAC) unit (a self-contained heating and cooling system). Resident #116 was observed with his head on the PTAC unit and his bottom on the floor. …
Based on record reviews, and staff, Nurse Practitioner and Medical Director interviews, the facility failed to ensure there was effective communication and assessments related to a resident's fall, which delayed medical evaluation and treatment. An X-ray of the right lower extremity completed on 5/25/26 revealed a supracondylar fracture in the distal femur (a break in the thigh bone just above the knee joint). The deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling and unsteadiness on feet, congestive heart failure, chronic kidney disease, and type II diabetes.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident… …
D · No harm, potential for more than minimal, isolatedSeptember 11, 2026
Based on record review, staff and Resident interviews, the facility failed to ensure a clinical assessment of injury was completed prior to transferring a resident by a mechanical lift after a fall. This deficient practice affected 1 of 3 residents reviewed for falls (Resident #45).Findings included:Resident #45 was admitted to the facility on [DATE] with diagnoses that included cardiomegaly (enlarged heart) and diabetes mellitus.Resident #45's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and was dependent on rolling from side to side, transferring and ambulation and required a wheelchair.Review of Resident #45's care plan revised on 06/22/25 revealed the Resident was at risk for falls related to a self-care performance deficit. …
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