Based on record review and staff, Medical Director, Physician Assistant (PA), and mobile x-ray provider interviews, the facility failed to notify a medical provider when the results of an x-ray revealing an intertrochanteric fracture of the right femur (type of broken hip that occurs between the bumpy parts at the top of the thigh bone) were reported to the facility on 3/19/25. This resulted in the fracture not being reported to PA #1 until 3/20/25 which delayed Resident #85's transfer to the hospital for evaluation and treatment. Resident #85 was sent to the hospital for an evaluation on 3/20/25 and on 3/21/25 Resident #85 received open reduction and internal fixation (a procedure to realign and secure broken bones with metal fasteners) to the right femur. …
F777 citations in North Carolina
Administration Deficiencies
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F777 more often than its own record predicts
7.73 times the share F777 takes of citations nationally.
Of every deficiency written in North Carolina in 2025, this is the portion that was F777.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F777 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 staff interviews and record review, the facility failed to: 1) Obtain a provider's order prior to requesting radiology testing (x-ray) be completed for a resident; and 2) Notify the Nurse Practitioner (NP) when the results of the x-ray revealing 4 rib fractures became available. This occurred for 1 of 3 residents (Resident #2) reviewed for accidents. The findings included: Resident #2 was admitted to the facility on [DATE] with cumulative diagnoses which included a history of stroke, generalized muscle weakness, and dementia. The resident's admission Minimum Data Set (MDS) dated [DATE] revealed she had severely impaired cognition. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2024 | 0.08% | 2.77× |
| 2025 | 0.19% | 7.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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