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The Carrolton of Lumberton

1170 Linkhaw Road, Lumberton, NC 28358 · For profit - Limited Liability company · 90 certified beds · (910) 671-1163 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Feb 2026
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
522 Peterson Dr · (910) 618-0900 · Call to confirm hours
Pharmacy
707 Farringdom St · (910) 802-4620 · Call to confirm hours
Grocery
Aldi0.6 mi
3725 Fayetteville Rd · (855) 955-2534 · Call to confirm hours
Park
500 Hornets Rd · Typically dawn to dusk
Place of worship
1270 Linkhaw Rd · (910) 738-5870

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.8%15.6%15.4%better
Long-stay residents who lose too much weight6.0%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.6%0.7%0.9%worse
Long-stay residents with a urinary tract infection2.6%2.3%2.0%worse
Long-stay residents with depressive symptoms1.5%5.9%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.5%3.5%3.3%worse
Long-stay residents whose ability to walk worsened26.9%18.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication34.8%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine97.5%94.1%95.3%typical
Long-stay residents with pressure ulcers10.3%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control11.1%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.0%14.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.6%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine59.6%78.1%79.4%worse
Short-stay residents rehospitalized after admission19.7%22.9%22.6%better
Short-stay residents with an outpatient ER visit17.2%12.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.561.781.67worse
Long-stay outpatient ER visits per 1,000 resident days4.111.801.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 67 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.0%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
40.9%U.S. median 56.6%
Met the expected recovery
0.24U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 40.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.0%CMS range 30.8–58.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.8–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge40.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge36.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge36.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 3.3–11.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.411.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.30
RN hours/ resident / day
0.97
LPN hours/ resident / day
2.87
Aide hours/ resident / day
4.13
Total nurse hours/ resident / day
0.18
RN hoursweekends
52.9%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 90 beds and averages 85.1 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.80 hrs/resident/day on weekends vs 4.27 on weekdays — 11% thinner on weekends. RN hours go from 0.35 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

9
deficiencies at the latest standard inspection (2026-02-19)
11
at the previous standard inspection (2024-11-21)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · E2026-02-19 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with resident, staff, Pharmacy Director and Nurse Practitioner, the facility failed to protect the residents' right to be free from misappropriation of narcotic pain medications (Tramadol, Hydrocodone-Acetaminophen, Oxycodone, and Oxycodone-Acetaminophen) for 9 of 9 residents reviewed for misappropriation of controlled medications (Residents #21, #2, #16, #34, #43, #52, #69, #79, and #87). Findings included: a.) Resident #21 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and debility. A physician's order with a start date of 10/16/23 which remained as an active order for Resident #21 revealed Tramadol 50 milligrams (mg) tablets, one tablet by mouth two times a day for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 10/27/25 at 7:09 PM a total of 30 Tramadol 50 mg tablets for Resident #21 were delivered to the facility. The delivery receipt was signed off as received by Nurse…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-19 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to obtain orders to access and manage a port-a-cath (an implantable device placed under the skin, usually in the chest, to provide long-term, easy access to veins for chemotherapy, medications, blood draws, or intravenous fluids) for 1 of 1 sampled resident with a port-a-cath (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses to include personal history of traumatic brain injury with persistent vegetative state. The hospital discharge summary completed on 12/20/2024 for Resident #1 revealed a left chest port-a-cath was placed by vascular surgery on 12/18/2024 for future access, but it was not yet mature (approximately 7 to 14 days for the site to heal to allow for use).A progress note written by the NP on 12/4/2025 revealed Resident #1 was admitted to the hospital on [DATE] for pneumonia and sepsis (a serious condition in which the body responds…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-19 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, Consultant Pharmacist, Pharmacy Nurse Consultant, and Pharmacy Director, the facility failed to have effective safeguards and systems in place for the accounting of controlled medications and the return of discontinued controlled medications to the pharmacy to prevent drug diversion for 9 of 9 residents reviewed for misappropriation of medications (Resident #69, #43, #2, #21, #16, #34, #52, #79, and #87). Findings included: a. A physician's order for Resident #69 with a start date of 8/8/25 revealed Lorazepam 0.5 milligrams (mg) tablets, one tablet by mouth every 24 hours as needed for anxiety for 14 days. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 8/8/25 at 7:13 PM a total of 14 Lorazepam 0.5 mg tablets were delivered to the facility for Resident #69. The delivery receipt was signed by Nurse #1 on 8/8/25. There was no signature on the delivery sheet from a second nurseThere was no declining count sheet (an inventory log…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-02-19 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and Consultant Pharmacist's interviews, the facility failed to a.) act on the Consultant Pharmacist's recommendation to address a residents (Resident #12) diuretic medication Metolazone (used to treat high blood pressure and fluid retention caused by heart failure or kidney disease) that was prescribed for increased edema. The Consultant Pharmacist reported during the monthly medication regimen review in October 2025 and November 2025 that Resident #12 was receiving Metolazone outside of the physician ordered parameters which were to hold the medication if the residents systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. b.) the Consultant Pharmacist failed to identify and address during the December 2025 and January 2026 monthly medication regimen reviews that Metolazone continued to be administered to Resident #12 outside of the ordered blood pressure parameters. This resulted in Resident #12 continuing to receive the medication when it…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-19 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff, resident, Nurse Practitioner and the Consultant Pharmacist interviews, the facility failed to hold the medication Metolazone (a diuretic medication used to treat high blood pressure and fluid retention caused by heart failure or kidney disease) when a resident's blood pressure was less than 110 systolic or less than 60 diastolic according to the parameters ordered by the physician. This resulted in a significant medication error as Resident #12 received 57 doses when the medication should have been held. Resident #12 experienced no significant outcome from receiving the medication. This occurred for 1 of 6 residents reviewed for medication administration (Resident #12). Findings included. Resident #12 was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, and kidney disease. A physician's order dated 9/5/25 for Resident #12 revealed Metolazone 5 milligram (mg) tablets. Give 1 tablet by mouth one time a day every Monday,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and Registered Dietician (RD) and staff interviews, the facility failed to honor residents' choices to have food items stored in the refrigerator and reheated for later consumption for 3 of 9 residents reviewed for self-determination (Resident #28, Resident #48, Resident #71).The findings included:a. Resident #28 was admitted to the facility on [DATE] with diagnoses to include acute unspecified protein calorie malnutrition.Review of Resident #28's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired and was coded independent for eating.The care plan dated 12/8/2025 for Resident #28 revealed a plan of care for risk for malnutrition related to weight loss, acute on chronic illness, and impaired mobility. The goal of care was for her intake of nutrients to meet her metabolic needs. Interventions included she was to receive her diet and supplements as prescribed.An interview with Resident #28 was completed on 2/10/2026 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and Nurse Practitioner interviews, the facility failed to provide effective supervision of a cognitively impaired resident (Resident #91) who was known to exhibit wandering behavior and rummaging. This failure resulted in Resident #91 obtaining and ingesting one gel capsule of an over-the-counter cold and flu medication containing acetaminophen, dextromethorphan (cough suppressant) and phenylephrine (nasal decongestant) that was in an unlocked drawer in the receptionist's desk located in the lobby area of the facility. This deficient practice was identified for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #91).Findings included:Resident #91 was admitted on [DATE] with a diagnosis which included Lewy body dementia, atrial fibrillation (irregular heart rate), hypertension, diabetes, chronic obstructive pulmonary disease, heart failure, thyroid disease and kidney disease.Resident #91's care plan dated 3/10/24 and currently active indicated that the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews, the facility failed to discard expired medications and record an opened date on ophthalmic drops that had shortened expiration dates on 2 of 6 medication carts that were reviewed for medication storage (200 hall medication cart #1 and medication cart #2). Findings included. a.) An observation of the 200-hall medication cart #1 on 2/10/26 at 2:50 PM along with Nurse #1 revealed the following medications: One bottle of Latanoprost .005% ophthalmic drops that was opened with no opened date labeled on the bottle. Review of the manufacturer's guidelines for Latanoprost ophthalmic solution instructed that once a bottle was opened for use, it may be stored at room temperature for 6 weeks then discarded. One bottle of Rocklatan ophthalmic drops that was opened with no opened date labeled on the bottle. Review of the manufacturer's guidelines for Rocklatan ophthalmic solution (a combination of two medications) instructed that once a bottle was opened for use, it may be stored at room temperature for 6 weeks then discarded. b.) An…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-19 · tag F0838 — failed to assess facility resources and resident needs — isolated
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure the facility assessment identified and addressed the care required for the population of residents with a port-a-cath (a small implanted device placed under the skin in the chest to provide easy, long-term access to a vein for chemotherapy, medication, intravenous (IV) fluids, or blood sampling), and to address the staff training necessary to competently provide port-a-cath care for residents for 1 of 1 resident (Resident #1).Findings included:Review of the facility assessment revealed the assessment was last updated on 9/8/2025. The document indicated the facility had completed education, training and competencies with staff specific to resident care needs; however, the document lacked training and competency to care for residents who required a port-a-cath.Resident #1 was admitted to the facility on [DATE]. Review of the electronic medical record (EMR) revealed Resident #1's port-a-cath was placed 12/18/2024 during a hospitalization for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-21 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage a day, 7 days a week for 13 of 139 days reviewed. Findings included: Review of the PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 2, 2024 (January 1-March 31, 2024) documented the facility had no RN coverage on 01/13/24, 01/20/24, 01/21/24, 02/03/24, 02/18/24, 02/24/24, 03/02/24, 03/24/24, and 03/30/24; and for Quarter 3, 2024 (April 1-June 30, 2024) on 04/06/24, 04/28/24, 05/04/24, 05/11/24, 05/12/24, and 05/26/24. Review of the facility daily staffing documentation revealed the DON (Director of Nursing) had worked 8 consecutive hours as a staff nurse on 01/21/24 and 04/06/24 after he had fulfilled his full time DON obligation (40 hours) as the DON for both weeks. In an interview with the Administrator on 11/19/24 at 12:44 PM he stated the facility had hired an RN Weekend Supervisor and there had been no recent issues with RN coverage. He noted that on some of the days that there was no weekend RN coverage the DON had worked as a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2024-11-21 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and Consulting Pharmacist and staff interviews, the facility failed to administer the physician ordered hypotensive medication (a medication to increase blood pressure) 6 times in one month when the blood pressure reading required the administration of the medication for 1 of 3 residents (Resident #18) sampled for medication review. Findings included: Resident #18 was admitted to the facility on [DATE]. Diagnoses included high blood pressure and Vitamin D deficiency. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #18 was moderately cognitively impaired. A physician's order written on 09/11/24 for Midodrine (medication used to treat orthostatic hypotension (sudden fall in blood pressure that can occur when a person assumes a standing position) 5 milligrams (mg) give one tablet by mouth as needed for blood pressure less than 110/60 millimeter of mercury (mm/Hg). A physician's order written on 11/15/24 for Metoprolol Tartrate (a medication to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 2 of 4 residents reviewed for abuse (Resident #35 and Resident #78). On 08/28/24 Resident #35 attempted to grab belongings out of Resident #84's hat, Resident #84 told him to stop but he continued. In response, Resident #84 grabbed Resident #35 by the arm and shook him causing Resident #35 to fall to the floor. Resident #84 then attempted to run Resident #35 over with his wheelchair. Resident #35 was not injured. On 09/23/24 Resident #78 entered Resident #76's room and Resident #76 slapped Resident #78 on the left cheek with an open hand and Resident #78 sustained mild redness to her left cheek which resolved within minutes after being assessed. Findings included: 1. Resident #35 was admitted to the facility on [DATE] with diagnoses that included, anxiety disorder, cognitive communication deficit, lack of coordination, and unsteadiness on his feet.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · tag F0626 — isolated
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Resident Representative (RR), Hospital Case Manager, Psychiatric Provider, and staff interviews, the facility failed to permit a resident to return to the facility after being transferred to the hospital for evaluation due to a resident to resident altercation for 1 of 1 resident reviewed for hospitalization (Resident #84). The findings included: Resident #84 was admitted to the facility 3/15/24 with diagnoses that included schizoaffective disorder, bipolar type and unspecified intracranial injury. Review of the facility Action Summary Report revealed Resident #84 had been discharged /transferred to another hospital on [DATE]. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident had moderately impaired cognition. He had physical and verbal behavioral symptoms directed towards other that occurred on 1 to 3 days. He used a wheelchair for mobility. He had a traumatic brain injury and schizophrenia. He had received antipsychotic and antidepressant medications…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and Consulting Pharmacist, Nurse Practitioner and staff interviews, the facility failed to a) clarify a physician's order for 26 days to determine the right dose to be administered for a daily topical medication to manage pain related to osteoarthritis (degeneration of bone that can cause pain) for Resident #60, b) follow the physician's orders to remove a lidocaine patch (medicated topical pain patch) after 12 hours of use to prevent potential skin irritation, redness, swelling, and/or discomfort for Resident #67 and c) to administer the correct ordered dose of a supplemental medication three times for Resident #18. This was for 3 of 3 residents sampled for medication review. Findings included: 1a. Resident #60 was admitted to the facility on [DATE]. Diagnoses included Dementia and osteoarthritis (type of degenerative joint disease). The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #60 was severely cognitively impaired. A physician order…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interview the facility failed to secure a resident's indwelling urinary catheter tubing to prevent tension or trauma for 1of 1 resident reviewed for urinary catheter (Resident #54). Findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer sacral region stage IV and dementia. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #54's cognition was moderately impaired, was incontinent of bowel and bladder, had a stage IV sacral pressure ulcer, and had an indwelling urinary catheter. Review of Resident #54's care plan revised 11/2024 addressed the use of an indwelling urinary catheter. Resident #54 had a stage IV pressure ulcer to her sacrum and potential for further pressure ulcer development and infections related to: mobility impairments, incontinent of bowel and bladder, diabetes, fragile skin integrity, and indwelling urinary catheter. A stage IV sacral pressure wound…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and Dialysis Nurse and staff interviews, the facility failed to follow the physician's orders to remove a dressing to an arterial venous fistula (a surgically created connection between artery and vein in the arm used for dialysis treatments) one hour after dialysis treatment to monitor for bleeding at the access cite and to prevent potential damage to the access cite for 1 of 2 residents (Resident #69) reviewed for dialysis. Findings included: Resident #69 was admitted to the facility on [DATE]. Diagnoses included, in part, end stage renal disease (ESRD) and dependent on dialysis. The MDS admission assessment dated [DATE] revealed Resident #69 was moderately cognitively impaired and was receiving dialysis services. Resident #69's care plan dated 10/22/24 revealed a plan of care for requiring hemodialysis with a goal that resident would have no signs or symptoms of complications from dialysis through the review date. Interventions to include, in part, monitor/document/report…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-21 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews the facility failed to ensure it was free of medication error rates greater than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 1 of 3 residents (Resident #60) observed during medication administration preparation. Findings included: Resident #60 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #60 was severely cognitively impaired. On 11/20/24 at 9:15 AM a medication administration preparation was observed with Nurse #7 for Resident #60. Nurse #7 was observed preparing the following medications for administration: Allopurinol (a medication to treat gout) 100 milligrams (mg) one tablet, Ciprofloxacin (an antibiotic medication to treat infection) 500 mg (2 tablets), Finasteride (a medication to treat enlarged prostate) 5 mg one tablet, Haldol (a medication to treat psychosis) 5 mg one tablet, Protonix (a medication to treat…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews the facility failed to discard expired opened multidose medications for 2 of 4 medication carts reviewed (300 and 400-hall medication carts). Findings included: a. An observation of the 300 Hall medication cart was conducted on 11/21/24 at 10:30 AM in the presence of Nurse #5. The medication cart contained an opened bottle of Geri-dryl (generic antihistamine brand of Benadryl) 25 milligrams (mg) with an expiration date of 10/24. An interview was conducted with Nurse #5 on 11/21/24 at 10:30 AM and she revealed the night shift nurses were supposed to check the medication carts during their shift for any expired medications. She stated she also checked her medication cart for expired medications but she overlooked the Geri-dryl bottle. Nurse #5 stated she did not administer any of this medication today. b. An observation of the 400 Hall medication cart was conducted on 11/21/24 at 11:30 AM in the presence of Nurse #5. The medication cart contained an opened bottle of Liquid Tylenol (pain relieving medication) 16 ounces with an expiration date…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility inaccurately documented the removal of a lidocaine patch (medicated topical pain patch) and the presence of a fall mat for 1 of 3 residents (Resident #67) observed during a medication pass, and inaccurately documented the removal of a dressing to an arterial venous access (vascular access to arm used for dialysis treatments) for 1 of 2 residents (Resident #69) observed for dialysis. Findings included: Resident #67 was admitted to the facility on [DATE]. Diagnoses included stroke with left side weakness, abnormalities of gait and mobility, lack of coordination, pain, and limitation of activities due to disability. 1a. A physician's order was written on 02/24/24 for Lidocaine external patch 4%, apply to back topically one time a day for pain. Remove after 12 hours. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #18 was cognitively intact and was on a pain medication regimen for occasional moderate pain. During a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and staff interviews, facility staff failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 and Nurse #3 failed to apply a gown before entering residents' room to provide care for 2 of 2 residents (Resident #40 and Resident #12). The deficient practice occurred for 2 of 2 staff members observed for infection control practices. Findings included: Review of the facility's policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 read in part: EBPs require use of gown and gloves by staff during high-contact patient care activities. During an observation on 11/20/24 and 11/21/24 an EBP sign was posted by Resident #40 and Resident #12's room door that read in part: All Health Personnel must: wear gloves and gown for the following high-contact resident care activities: Device care or use for tracheostomy, or wound care, with any skin opening requiring a dressing. a. An observation was conducted on 11/20/24 at 2:05 PM of Nurse #3 providing tracheostomy care for Resident #40. Nurse #3 performed hand hygiene upon…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-25 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, Consultant Pharmacist and Psychiatrist interviews, the facility failed to 1.a) provide an indication for an antipsychotic medication (Thiothixene-prescribed for treatment of Schizophrenia) b) complete an Abnormal Involuntary Movement Scale (AIMS) assessment which is used for medication monitoring to assess for side effects of antipsychotic medications for 1 of 5 residents (Resident #41). 2) Include a stop date for an as needed psychotropic medication for 1 of 5 residents (Resident # 42 ) reviewed for unnecessary medications. Findings included. 1.a) Resident #41 was admitted to the facility on [DATE] with diagnoses including mood disorder, depression, cognitive communication deficit, and failure to thrive. The hospital Discharge summary dated [DATE] for Resident #41 revealed Thiothixene 2 milligram (mg) capsules, take 4 mgs by mouth every night- patient reported medication. There was no diagnosis listed for this medication on the hospital discharge summary. A review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-25 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to administer the pneumococcal vaccine after obtaining informed consent for 4 of 5 residents (Resident #7, #6, #1, #16) and offer and obtain consent for 1 of 5 residents (Resident #24) reviewed for immunizations. Findings included. A review of the facility's pneumococcal vaccine policy revised 09/14/22 read in part; each resident would be assessed for pneumococcal immunization upon admission. Each resident would be offered a pneumococcal immunization unless it was medically contraindicated, or the resident had already been immunized. A pneumococcal vaccine was recommended for all adults 65 years and older, and for adults 19 to [AGE] years old who had certain chronic medical conditions including in part; heart disease, lung disease, renal failure, diabetes, or other risk factors. a. Resident #7 was admitted to the facility on [DATE] with diagnoses including dementia, renal disease, and hypertension. A review of Resident #7's medical record revealed a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to complete comprehensive assessments within the 14-day required timeframe for 3 of 15 residents (Resident #17, Resident #42, and Resident #5) reviewed for comprehensive Minimum Data Set (MDS) assessments. Findings included: 1. Resident #17 was admitted to the facility on [DATE]. Resident #17's admission MDS dated [DATE] was completed on 05/15/2023. An interview with the MDS Nurse was conducted on 05/25/2023 at 1:25 P.M. The MDS Nurse stated that she got behind completing the MDS assessments when she was the interim Director of Nursing (DON). She stated the current DON was hired in February and she had not had a chance to catch the assessments up to date yet. An interview was conducted with the DON on 05/25/2023 at 3:35 P.M. The DON stated the MDS Nurse was the interim DON until she was hired in February. She further stated the MDS Nurse had gotten behind with the MDS assessments and she was trying to get them submitted within the required…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, Medical Director, and Psychiatrist interviews, the facility failed to initiate psychiatric services according to the level 2 PASRR (Preadmission Screening Resident Review - a required screening to ensure residents with serious mental illness, intellectual, or developmental disabilities received appropriate placement and services) for 1 of 3 residents (Resident #1) reviewed for PASRR compliance. Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including Schizophrenia and Bipolar. Review of the Level 2 PASRR determination notification dated 02/01/23 revealed that based on the evaluation and recommendations Resident #1 was to receive specialized psychiatric services provided by a psychiatrist. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was cognitively intact. She was currently considered by the state level II PASRR process to have serious mental illness. She exhibited no physical or verbal behaviors,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and Pharmacy Consultant interviews the facility failed to store controlled substances in a permanently affixed compartment of the refrigerator in the only medication storage room currently in use at the facility. Findings included: An observation of the locked medication storage room was conducted with the Director of Nursing (DON) on 05/23/2023 at 1:16 P.M. The refrigerator was not locked and contained 1 small metal box locked with a small padlock and it was not permanently affixed to the refrigerator and 1 small metal box locked with a small padlock attached and it was permanently affixed to the refrigerator. The small metal box that was not permanently affixed contained a single dose of liquid lorazepam (an antianxiety medication) intramuscular (IM)/intravenous (IV) 2 milligram (mg) per milliliter (ml). The DON stated the small metal box that was not permanently affixed to the refrigerator contained a controlled medication for a specific resident and the key was kept by the nurse on the 300 Hall. She further stated the permanently affixed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to maintain an accurate Medication Administration Record (MAR) for 1 of 16 residents (Resident #205). Findings included: Resident #205 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD) and chronic kidney disease. Review of the admission orders dated 05/23/2023 for Resident #205 revealed an order for Incruse Ellipta inhalation aerosol powder breath activated 62.5 micrograms (mcg) (Umeclidinium Bromide) 1 puff inhale orally one time a day related to COPD. There was not a Minimum Data Set (MDS) assessment completed for Resident #205 because he was a new admission. An observation of Nurse #1 administering medications to Resident #205 was conducted on 05/25/2023 at 09:06 AM. Resident #205 was not administered an inhaler during the observation. Review of Resident #205's May 2023 MAR revealed Incruse Ellipta inhalation aerosol powder breath activated 62.5 mcg (Umeclidinium…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews the facility failed to follow the manufacturer's guidelines for cleaning and disinfection of a blood glucose meter which was stored in the medication cart after use for 1of 1 resident observed for blood glucose monitoring (Resident #205). Findings included: Review of the facility's policy Blood Glucose (Sugar) Monitoring implemented December 2022, read in part to follow manufacturer's directions for use and care of the glucose meter. The blood glucose meter manufacturer's instructions for cleaning and disinfecting the meter revised August 2015, indicated the blood glucose meter could only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. The meter should be cleaned and disinfected after use on each patient. The instructions listed Environmental Protection Agency (EPA) registered wipes that had been tested and approved for cleaning and disinfecting the blood glucose glucometer. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-05-25 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and Ombudsman interview the facility failed to notify the Regional Ombudsman of discharge to the hospital for 2 of 2 residents reviewed for discharge (Resident #34, Resident # 41). The findings included: 1. Resident #34 was admitted [DATE] and discharged to the hospital on 1/24/23. An interview on 5/25/23 at 1:20 PM, the Social Worker (SW) stated she did not notify the Regional Ombudsman of Resident #34's discharge to the hospital on 1/24/23. She stated she was not sure if was the Business Office Managers' or her responsibility to notify the Regional Ombudsman. An interview on 5/25/23 at 1:26 PM the Human Resources staff stated she did not send any list to the Ombudsman; she thought the Social Worker did. An interview on 5/25/23 at 1:36 PM the Regional Ombudsman revealed she had not been receiving a list of residents who were sent to the hospital. An interview on 5/25/23 at 1:58 PM the Administrator stated he thought Human Resources was sending the resident list to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARROLTON NURSING HOMES — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.3-1.3 vs chain
Health inspection 2 of 52.5-0.5 vs chain
Staffing 3 of 52.0+1.0 vs chain
Quality measures 1 of 52.2-1.2 vs chain
The other 5 homes this chain runs (chain average 2.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
C. SAUNDERS ROBERSON, JR., AS TRUSTEE OF THE JUDITH ROBERSON DIXON IRROrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 02/21/2020
FIGLEWSKI, DEBORAHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 02/21/2020
POWELL, EARLIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 02/21/2020
POWELL, JOHNIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 02/21/2020
RUSSELL, DENISEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 02/21/2020
CARROLTON FACILITY MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2020
ROBERSON, CARROLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2020
ROZIER, SONYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2020

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.4M
Net patient revenuemost recent cost report
-25.3%
Operating marginrevenue minus expenses
$921K
Related-party expense10% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 12%Other / private 14%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $921K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$470per resident / day
operating cost
$14,278per month
≈ monthly operating cost
$375per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345315. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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