Based on record review, staff, hospice and emergency medical technician interviews, the facility failed to notify Hospice of a Residents acute change in condition resulting in an unnecessary transfer to the hospital and intubation for 1 of 1 sampled resident. (Resident #1) Findings Include: Record review of the Hospice Nursing Facility Services Agreement dated [DATE] revealed in section: Monitoring of Residential Hospice Patient Nursing facility shall immediately inform Hospice of any change of condition of a Residential Hospice Patient. Patient Transfer Nursing facility agrees not to transfer any Residential Hospice Patient to another care setting without the prior approval of hospice. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . …
F849 citations in North Carolina
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Carolina cites F849 less often than its own record predicts
0.89 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 F849.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F849 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, Physician #1, Physician #2, Hospice Clinical Manger, the Hospice Nurse and staff interviews, the facility failed to have effective systems in place to ensure hospice orders were processed when a resident was admitted to hospice services for 1 of 1 resident reviewed for hospice services (Resident #16). The findings included:Resident #16 was readmitted to the facility on [DATE] with diagnoses including failure to thrive, congestive heart failure, dementia, chronic respiratory failure, and diabetes. She was admitted to hospice services on 2/7/26. …
Based on observation, record review, staff interviews the facility failed to obtain a Physician's order for hospice services for 2 of 4 residents (Residents #58 and #259) reviewed for hospice. Findings included: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set, dated dated dated [DATE] indicated that Resident #58 had severe cognitive impairment and was coded for hospice. Review of Resident #58's electronic medical health record and paper chart revealed no order for hospice. An interview on 6/28/22 at 10:35 AM with the Director of Nursing revealed that the resident should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.29% | 0.92× |
| 2024 | 0.24% | 0.78× |
| 2025 | 0.24% | 0.89× |
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