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1638 OWEN DRIVE P O BOX 2000 FAYETTEVILLE, NC 28302 | Voluntary non-profit - Private

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Health deficiencies are assigned during inspections that assess compliance with rules related to patient health and safety. Examples include violations of patients' rights and safety standards, as well as the administration of drugs and other treatments.

Life Safety deficiencies are assigned during inspections that assess a facility's compliance with National Fire Protection Association codes related to life safety in health care facilities. They are often conducted in tandem with health inspections. Examples include faulty or improperly maintained fire suppression and electrical systems.

Emergency Preparedness deficiencies can be cited during either a health or life safety inspection and relate to violations of CMS' Emergency Preparedness Rule. Examples include a lack of emergency plans, inadequate staff training and insufficient emergency supplies.

Complete reports and deficiency counts

Report date	Health Deficiencies	Life Safety	Emergency Preparedness	Total
Nov 20, 2024	2	0	0	2	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: GRIEVANCES USE OF RESTRAINT OR SECLUSION
Nov 19, 2024	1	0	0	1	Read full report
Deficiencies cited in this report: MEDICAL SCREENING EXAM
Feb 7, 2024	1	0	0	1	Read full report
Deficiencies cited in this report: EMERGENCY SERVICES POLICIES
Feb 24, 2022	7	0	0	7	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT SAFETY NURSING SERVICES RN SUPERVISION OF NURSING CARE SUPERVISION OF CONTRACT STAFF
Feb 23, 2022	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM
Jul 22, 2021	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: NOTICE OF RIGHTS
Apr 14, 2021	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM
Nov 4, 2020	2	0	0	2	Read full report
Deficiencies cited in this report: QUALITY IMPROVEMENT ACTIVITIES WRITTEN DESCRIPTION OF SERVICES
Jan 9, 2020	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE INFECTION CONTROL PROGRAM
Aug 21, 2019	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION
Jul 18, 2018	1	0	0	1	Read full report
Deficiencies cited in this report: ADMINISTRATION OF DRUGS
Dec 13, 2017	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM
May 25, 2017	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 RECIPIENT HOSPITAL RESPONSIBILITIES
Dec 8, 2016	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE RN SUPERVISION OF NURSING CARE
May 6, 2016	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
Sep 18, 2015	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE RN SUPERVISION OF NURSING CARE
Jul 23, 2015	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE ORDERS FOR DRUGS AND BIOLOGICALS
Jan 29, 2015	1	0	0	1	Read full report
Deficiencies cited in this report: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
Feb 26, 2014	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION
Nov 7, 2013	5	0	0	5	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM STABILIZING TREATMENT MEDICAL SCREENING EXAM STABILIZING TREATMENT
Sep 5, 2013	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE DISCHARGE PLANNING EVALUATION
Jan 10, 2013	0	14	0	14	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available
Jan 10, 2013	8	0	0	8	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS: CARE IN SAFE SETTING PHARMACY DRUG RECORDS PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT LIFE SAFETY FROM FIRE LIFE SAFETY FROM FIRE INFECTION CONTROL PROGRAM
Feb 22, 2012	7	0	0	7	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM STABILIZING TREATMENT APPROPRIATE TRANSFER MEDICAL SCREENING EXAM STABILIZING TREATMENT APPROPRIATE TRANSFER
Jan 26, 2012	14	0	0	14	Read full report
Deficiencies cited in this report: GOVERNING BODY QAPI No Description Available No Description Available NURSING SERVICES RN SUPERVISION OF NURSING CARE No Description Available INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM DATA COLLECTION & ANALYSIS PATIENT SAFETY QUALITY IMPROVEMENT ACTIVITIES ADMINISTRATION OF DRUGS INFECTION CONTROL PROGRAM
Jan 5, 2012	1	0	0	1	Read full report
Deficiencies cited in this report: SUPERVISION OF CONTRACT STAFF
Dec 22, 2011	8	0	0	8	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING NURSING SERVICES RN SUPERVISION OF NURSING CARE ADMINISTRATION OF DRUGS PATIENT RIGHTS: CARE IN SAFE SETTING RN SUPERVISION OF NURSING CARE
Nov 30, 2011	7	0	0	7	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING NURSING SERVICES RN SUPERVISION OF NURSING CARE PATIENT RIGHTS: CARE IN SAFE SETTING RN SUPERVISION OF NURSING CARE
Nov 17, 2011	3	0	0	3	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 MEDICAL SCREENING EXAM MEDICAL SCREENING EXAM
Nov 17, 2011	23	0	0	23	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING QAPI No Description Available NURSING SERVICES RN SUPERVISION OF NURSING CARE PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT EMERGENCY POWER AND LIGHTING LIFE SAFETY FROM FIRE LIFE SAFETY FROM FIRE DISPOSAL OF TRASH OPERATIVE REPORT EMERGENCY SERVICES ORGANIZATION AND DIRECTION OPERATIVE REPORT RN SUPERVISION OF NURSING CARE PATIENT RIGHTS: CARE IN SAFE SETTING ORGANIZATION AND DIRECTION DATA COLLECTION & ANALYSIS PATIENT SAFETY LIFE SAFETY FROM FIRE
Nov 16, 2011	0	22	0	22	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available
Oct 21, 2011	28	0	0	28	Read full report
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION QAPI No Description Available No Description Available No Description Available NURSING SERVICES RN SUPERVISION OF NURSING CARE PATIENT CARE ASSIGNMENTS PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION DATA COLLECTION & ANALYSIS PATIENT SAFETY QUALITY IMPROVEMENT ACTIVITIES RN SUPERVISION OF NURSING CARE PATIENT CARE ASSIGNMENTS PATIENT SAFETY
Mar 4, 2011	3	0	0	3	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 APPROPRIATE TRANSFER APPROPRIATE TRANSFER
Mar 3, 2011	2	0	0	2	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE RN SUPERVISION OF NURSING CARE
Dec 15, 2010	1	0	0	1	Read full report
Deficiencies cited in this report: RN SUPERVISION OF NURSING CARE

Some state health departments and regional offices of the Centers for Medicare and Medicaid Services sometimes did not upload their inspection reports into a central computer system that could then be shared by us. In such cases, CMS identified the dates of the missing inspections and the number of deficiencies identified. You can request the actual reports from CMS or your state health department.

* Deficiencies cited in follow-up inspections are not counted toward a facility's total deficiency count.

HospitalInspections.org

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Complete reports and deficiency counts