Based on record review, observation, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to provide effective leadership and implement effective systems to manage and supervise a resident with a history of substance abuse after syringes were found in Resident #52's room and protect all residents after Resident #52 reported Nurse Aide #1 was providing her with methamphetamine and syringes. This failure had a high likelihood of affecting other facility residents. Immediate jeopardy started on 10/5/23 when after observing drug paraphernalia in Resident #52's room the facility's administrative team failed to identify the seriousness of the situation and put effective systems in place. …
F835 citations in North Carolina
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F835 less often than its own record predicts
0.16 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 F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F835 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, observation, and interviews with resident representative and staff, the facility failed to provide effective leadership and oversight to ensure systems and policies were implemented related to COVID-19 staff vaccinations for 3 of 3 dietary staff (Dietary Aide #1, Dietary Aide #2, and Dietary Aide #3), resident vaccinations for 1 of 5 residents (Resident #39), and staff testing for 3 of 3 unvaccinated staff (Nurse #3, Nurse Aide #3 and Housekeeper #1). The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39,… …
Based on document review, interview, record review, and policy review, the facility's Administrator and Director of Nursing (DON) failed to identify there was no physician order in the electronic medical record (EMR) orders to correctly identify all residents' code status, and failed to provide oversight of staff's audits of residents' EMR Code Status to ensure the audits were accurate and to make corrections to ensure sustained compliance with the citation which had the potential to affect 72 of 72 residents who resided in the facility. The findings include: During an interview on 11/14/25 at 5:28 PM, the Administrator could not provide audit tools related to the monitoring of code status in resident records. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.14% | 0.50× |
| 2024 | 0.36% | 1.09× |
| 2025 | 0.05% | 0.16× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction