Based on record review, Resident, former staff, Corporate Human Resources Representative and current staff interviews, the Governing Body or its designated person failed to have the Business Office Manager sign a Duty to Disclose Conflict of Interest form and approve or deny a plan to purchase property from a resident for 1 of 1 resident (Resident #8) reviewed for compliance and ethics policy implementation. The findings included: A review of the facility's Ethical Business Practices and Conflicts of Interest policy effective April 2015 (last revised 1/18/2024) stated employees are expected to conduct themselves to avoid actual impropriety and/or the appearance of impropriety in making business decisions. …
F895 citations in North Carolina
Administration Deficiencies
Have a Compliance and Ethics Program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
North Carolina cites F895 more often than its own record predicts
3.23 times the share F895 takes of citations nationally.
Of every deficiency written in North Carolina in 2024, this is the portion that was F895.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F895 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.
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