Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Carrolton Of Dunn during CMS and state inspections, most recent first.
The facility did not maintain the required 8 hours of RN coverage on two reviewed days when the scheduled weekend RN called out and no replacement RN was provided. Review of daily staffing postings confirmed there was no RN scheduled for those days. The DON reported not being notified of the RN call‑outs and only learned of the lack of RN coverage afterward, despite knowing the requirement for daily RN coverage and expecting to be informed of such absences. The Administrator also stated an expectation that RN coverage be provided 8 hours a day, 7 days a week.
The facility failed to provide required CMS Skilled Nursing Facility Advanced Beneficiary Notification (SNF-ABN) forms to two residents when their Medicare Part A skilled services were discontinued before all covered days were used, while they remained in the facility. In both cases, the insurance company initiated the end of Part A coverage and sent a CMS Notice of Medicare Non-Coverage (NOMNC), which the facility completed and issued, but no SNF-ABN was given. The BOM and SW reported they were unaware that both a NOMNC and a SNF-ABN were required and that the SNF-ABN includes estimated out-of-pocket costs, and the Administrator stated he expected appropriate notices to be provided but had not seen the SNF-ABN used at the facility.
Surveyors found that dietary staff failed to properly store and monitor food and ensure dish cleanliness. Spoiled produce with visible mold and slime was present in the walk-in cooler, and open bags of frozen meatballs, French fries, and peas in the freezer were left unsealed, undated, and covered with ice crystals. On the tray line, multiple bowls, pans, plates, and plate covers labeled as clean were stacked while still wet, and several plates and covers had visible black, yellow, and brown spots. The Dietary Manager reported she had recently started in the role, that the dishwashing staff member was new, and that she personally checked for dating and spoilage on a set schedule, without identifying other staff responsible. The Administrator stated he had been informed of wet dishes and undated food but was not aware of spoiled food and expected dietary staff to label and date open items, keep dishes dry, and discard spoiled food.
The facility removed a microwave that residents and families had previously used to heat outside food, and staff refused to heat any food not prepared by the kitchen, citing safety and temperature-monitoring concerns. Cognitively intact residents with conditions such as diabetes, GERD, and depression, who were independent with eating, reported they could no longer warm soups and other items brought by family and were told they must eat such food cold or not at all. Nursing staff, the Dietary Manager, the DON, and the Administrator confirmed that the microwave was removed for safety reasons, that no alternative method was provided for heating outside food, and that residents and families were upset about the loss of this choice.
A cognitively intact resident told the Admissions Director that a nurse aide had hit her in the face multiple times during bathing, but the Admissions Director only completed a grievance form and did not notify the DON or Administrator until the next morning. This delay caused the Administrator to document the facility’s awareness of the allegation as occurring later than it actually did and to submit an initial report to the State Agency that did not accurately reflect when the allegation was first made or include timely notification to APS and law enforcement as required by facility policy.
Staff failed to knock or request permission before entering the rooms of three residents, including individuals with varying levels of cognitive impairment, while delivering lunch trays. The nurse aide involved acknowledged awareness of the requirement but did not follow it, and other staff confirmed that knocking and announcing oneself is expected to maintain resident dignity.
A resident who was initially progressing in rehabilitation experienced a significant decline, including decreased responsiveness, poor oral intake, and new symptoms such as dizziness and dark stools. Despite multiple therapy and nursing staff observing and documenting these changes, there was a failure to notify the physician in a timely manner. The resident was later hospitalized in critical condition with sepsis and gastrointestinal bleeding.
A resident with a history of stroke and anemia experienced a significant decline in condition, including new symptoms and decreased responsiveness, which was observed by therapy and aide staff but not effectively communicated or acted upon by nursing. Physician-ordered labs were not completed, and after testing positive for COVID, the resident did not receive timely evaluation or treatment for her infection or decline until hospital transfer, where she was found to be septic and severely anemic.
A nurse in an LTC facility failed to follow physician orders for continuous tube feeding for two residents, turning off the pumps without authorization. This action deprived the residents of necessary nutrition and was not documented in their medical records. The facility's DON and RD were unaware of the nurse's actions, which placed the residents at risk of harm.
A nurse in an LTC facility turned off the feeding tube pumps for two residents without notifying the physician, deviating from continuous feeding orders. This action deprived the residents of their nutritional needs, as the nurse believed their stomachs needed a rest. The facility failed to ensure physician notification and adherence to prescribed orders, leading to a deficiency.
The facility failed to complete quarterly MDS assessments within the required 14-day timeframe for eight residents due to staffing issues. The assessments were either incomplete or completed late, with the facility relying on a part-time MDS nurse. The Administrator was aware of the backlog and had hired additional MDS nurses to address the issue.
Three residents in an LTC facility did not receive tube feedings as ordered by their physicians. A nurse turned off the feeding pumps for two residents without physician orders, believing their stomachs needed rest, and did not document these actions. Another resident's feeding pump was set at a lower rate than ordered, impacting their nutritional intake. The facility's staff failed to notify physicians of these changes, potentially affecting the residents' health.
A resident with cognitive impairment and incontinence was not provided timely incontinence care, resulting in a saturated adult brief. The resident's care plan required frequent checks, but staff failed to adhere to this due to misunderstandings and prioritization of other duties. The DON confirmed the need for two-hour checks due to the resident's health changes.
A facility failed to conduct and document an admission screening assessment for a resident readmitted after hospitalization. The resident, with non-Alzheimer's dementia and a hip fracture, required assistance with daily activities. The DON did not complete the assessment or communicate its necessity to the night shift nurse, resulting in a lack of documentation of the resident's cognitive and functional levels.
A facility failed to ensure a resident's code status was accurately documented, leading to potential misinterpretation of resuscitation orders. The resident's representative requested a DNR order upon admission, but the order was not properly recorded in the medical record. A nurse believed the resident had a full code status based on a report, but found conflicting information in the chart. The issue was identified by a surveyor, revealing a lapse in the facility's documentation process.
A facility failed to complete the admission MDS assessment within the required timeframe for a newly admitted resident. The delay was due to a lack of full-time MDS staff for about three months, resulting in a backlog of incomplete assessments. The MDS Nurse acknowledged the issue, and the Administrator confirmed that additional MDS nurses had been hired to address the backlog.
A facility failed to conduct a PASRR Level 2 for a resident with schizophrenia and bipolar disorder. The resident was admitted with a PASRR Level 1 assessment, which did not recognize their mental illness. Despite being prescribed Haloperidol, the PASRR Level 2 was not initiated until an inquiry was made. The Social Worker had not reviewed the resident's diagnoses upon admission, and the Clinical Nurse Consultant and Administrator acknowledged the oversight.
A facility failed to create a baseline care plan within 48 hours for a resident with significant medical needs, including a brain bleed, dysphagia, and an unhealed Stage IV wound. The resident was unable to speak or understand others and could not participate in assessments. The DON confirmed the absence of the required care plan, which should have been completed by the charge nurse.
The facility did not have an RN on duty for 8 consecutive hours daily on three occasions due to a lack of available RNs, despite offering overtime and bonuses. The schedule only included LPNs and medication aides, and the Administrator was unaware of this staffing deficiency.
A facility failed to address a Consultant Pharmacist's recommendation for an AIMS assessment for a resident on antipsychotic medication. Despite monthly reviews and communication from the pharmacist, the assessment was not conducted, and no response was documented. Interviews revealed communication lapses among the Interim DON, the new DON, and nursing staff, leading to the oversight.
An expired insulin aspart flex pen was found on a medication cart, despite being opened beyond the recommended 28-day period. The DON confirmed the oversight and removed the expired pen. Medication Aide #1 was unaware of the expiration period, and the Chief Clinical Officer stated that medication carts are regularly checked for expired medications.
The facility failed to maintain an effective pest control program, resulting in mice sightings and evidence of mice presence in two halls. Cognitively intact residents reported seeing mice and finding droppings in their rooms. Pest control logs showed treatments in 2023, but no documentation since October. The Maintenance Supervisor confirmed increased mice presence and acknowledged verbal complaints from staff, but no official work requests were made. The administrator confirmed ongoing reports of mice.
The facility failed to report allegations of abuse and neglect to APS for three residents. One resident alleged verbal abuse, another alleged neglect causing skin breakdown, and a third alleged neglect due to lack of hygiene care. The facility notified local law enforcement but did not notify APS, as confirmed by blank notification areas in the investigation reports. The Administrator was unaware of the requirement to notify APS.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of RN coverage per day on two days within a 30‑day staffing review period. Review of daily nurse staffing postings for 8/10/25 through 9/10/25 showed that no RN was scheduled for at least 8 hours on 8/30/25 and 8/31/25. During interview, the DON reported there was no RN coverage in the facility on those two days because the scheduled weekend RN called out, and the DON was not notified of the call‑outs at the time. The DON stated she did not learn that the facility had no RN coverage on those dates until the following Monday morning and acknowledged awareness of the requirement for 8 hours of RN coverage each day, as well as an expectation to be notified when an RN calls out. In a separate interview, the Administrator stated he expected the facility to have RN coverage 8 hours a day, 7 days a week. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Issue Required SNF-ABN Notices When Medicare Part A Services Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide required Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notification (SNF-ABN) forms when Medicare Part A skilled services were discontinued before the exhaustion of the 100 covered days, while the residents remained in the facility. For one resident whose Medicare Part A skilled stay began on 5/19/25 and ended on 5/30/25, record review showed no evidence that a SNF-ABN was issued, even though the resident had remaining covered days and continued to reside at the facility. The Business Office Manager (BOM) stated that the resident’s discharge from Medicare Part A services was initiated by the insurance company, which emailed a CMS Notice of Medicare Non-Coverage (NOMNC) for the facility to present, and acknowledged she was not aware that a SNF-ABN also needed to be provided. The Social Worker (SW) interviewed, who was not employed at the time of this resident’s NOMNC issuance, reported that the SW role had been limited to providing the NOMNC and that she had never provided a SNF-ABN, and was unaware that both notices were required. A second resident was admitted under Medicare Part A skilled services beginning 8/19/25, with covered services ending on 9/5/25, and also remained in the facility with Medicare days still available. Review of this resident’s record likewise revealed no SNF-ABN. The BOM reported that this resident’s discharge from Medicare Part A services was also initiated by the insurance company, which sent a blank NOMNC form for completion and delivery to the resident, and again stated she did not know a SNF-ABN was required. The SW confirmed she had issued the NOMNC for this resident at the time Part A services ended, but was not aware she was required to provide both a NOMNC and a SNF-ABN and did not know about the SNF-ABN form that includes an estimated out-of-pocket cost. The Administrator acknowledged awareness of both the SNF-ABN and NOMNC forms and stated his expectation that appropriate notices would have been given, but indicated he had not seen the SNF-ABN form used at this facility.
Improper Food Storage and Dishwashing Practices in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and monitoring of food items, as well as inadequate dishwashing practices. During an observation of the walk-in cooler with the Dietary Manager, all five cantaloupes were found with soft, brown and black spots and white fuzz, and all fourteen heads of lettuce were brown, slimy, and had spots of white fuzz, indicating spoilage that had not been discarded. In the walk-in freezer, surveyors observed partially used bags of meatballs, French fries, and peas that were open to the air, undated, and had a layer of ice crystals, showing that open frozen foods were not being properly sealed and dated. On the tray line, surveyors observed that dishes and service ware that were designated as clean and ready for use were not properly dried or clean. Eleven of twelve bowls, two of three quarter pans, ten of ten divided plates, and thirty-one of fifty-seven plate covers were stacked while still wet. Additionally, seven of ten divided plates and two of fifty-seven plate covers had visible black, yellow, and brown spots on them. In interviews, the Dietary Manager reported she had been in her role for about three months and that the dishwashing staff member was new; she stated she had educated him that dishes must be dry before stacking and checked for cleanliness before being placed on the tray line. She also stated she personally went through the kitchen on Mondays to ensure items were dated and that spoiled food was discarded, and did not identify other staff responsible for this task. The Administrator stated he had been informed of wet dishes and undated food but was unaware of food with signs of spoilage, and he expected dietary staff to label and date open food items, stack dishes dry, and dispose of spoiled food.
Failure to Honor Resident Choice to Heat Outside Food After Microwave Removal
Penalty
Summary
The deficiency involves the facility’s failure to honor resident choice regarding warming meals brought from outside the facility after the removal of a resident-accessible microwave. Three cognitively intact residents who were independent with eating, some with diagnoses including type 2 diabetes mellitus, anxiety disorder, GERD, and depression, reported that they had previously used a microwave in the dining room to heat soups and other foods brought by family. About a month to a month and a half before the survey, the microwave was removed from the dining room. Residents stated they were told by kitchen staff that personal food items could not be brought into the kitchen to be heated and that the change was due to safety concerns. As a result, residents who did not like the facility’s meals or alternatives, or who wished to save outside food for later, were left with food they could only eat cold or not at all. Staff interviews confirmed that there was no longer any access to a microwave for residents’ food and that the microwave had been removed for safety reasons, including concerns about monitoring food temperatures and the possibility of residents burning themselves. Nurse staff acknowledged that residents and families were upset about the change and that families were informed they would need to bring food already warmed. The Dietary Manager stated she was told by management that the microwave was removed due to safety concerns and that outside food could not be brought into the kitchen to be heated, even though comparable soup could be provided from the kitchen. The DON and Administrator both stated the microwave was removed from the dining room for safety reasons, including inability to monitor temperatures of microwaved foods and concerns about burns, and confirmed that no residents had been injured while using the microwave prior to its removal. These actions and inactions resulted in residents’ expressed dissatisfaction and loss of the ability to exercise choice in heating and consuming outside food items.
Failure to Timely and Accurately Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy requiring immediate reporting of abuse allegations to the Administrator, State Agency, Adult Protective Services (APS), and law enforcement when applicable, within two hours of the allegation. A cognitively intact resident reported to the Admissions Director that a nurse aide had hit her in the face multiple times during a shower/bed bath, describing the staff member as a Black woman with pearls in her hair. The Admissions Director documented the concern on a grievance form but did not notify nursing staff, the DON, or the Administrator until the following morning during a meeting, citing that it was late, had been a long day, and that she had not observed any visible injuries on the resident at the time. As a result, the Administrator recorded the facility’s awareness date and time of the allegation as the following day, rather than when the Admissions Director first received the report from the resident. The initial allegation report completed by the Administrator documented that the facility first became aware of the abuse allegation on the later date and did not reflect the actual date and time the allegation was first reported to staff. The initial report was faxed to the State Agency several hours after the Administrator was informed, and the initial documentation did not show that APS or law enforcement were notified at that time. A subsequent skin assessment by a nurse, completed at the request of the Facility Nurse Consultant, documented no signs of facial trauma or other skin issues aside from a pressure spot on the resident’s toe. Interviews with the DON and Administrator confirmed that staff were expected to report any abuse allegation immediately so it could be reported to the State Agency within two hours, and that the Admissions Director did not follow this requirement, resulting in delayed and inaccurate reporting of the abuse allegation.
Failure to Knock or Request Permission Before Entering Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility's treatment of residents' dignity and rights, specifically related to staff failing to knock or ask permission before entering resident rooms. Observations revealed that a nurse aide entered the rooms of three residents without knocking on multiple occasions while delivering lunch trays. The nurse aide acknowledged during interviews that she was aware of the expectation to knock and announce herself but could not explain why she did not follow this protocol. Other staff, including the wound nurse and the administrator, confirmed that staff are expected to knock and introduce themselves before entering resident rooms. The residents involved included one with severe cognitive impairment, one who was cognitively intact, and one with moderate cognitive impairment. Attempts to interview two of the residents were unsuccessful, while the third resident did not express an opinion about the staff's actions. The deficiency was determined based on the reasonable person concept, as individuals generally expect staff to knock and identify themselves before entering their rooms.
Failure to Notify Physician of Resident's Significant Decline
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition, despite multiple staff members observing a marked decline. The resident, who was admitted for rehabilitation following a stroke and was initially making progress in therapy, began to exhibit symptoms such as dizziness, lightheadedness, nausea, altered responsiveness, decreased communication, dry mouth, poor oral intake, reduced urine output, dark stools, and eventually tested positive for COVID. Therapy and nursing staff documented and discussed the resident's decline, but there was no timely communication with the physician regarding these changes. Throughout the resident's stay, therapy staff and nurse aides noted a regression in the resident's functional abilities, including a loss of ability to feed herself, ambulate, and communicate as she had previously. Multiple therapy notes and staff interviews indicated that the resident required increasing assistance, became less responsive, and was unable to participate in therapy or self-care. Despite these observations and documentation of the resident's deteriorating condition, the physician was not notified for several days. The only documented physician notification prior to the resident's hospital transfer was related to facial twitching, for which a medication was ordered, but subsequent and more severe changes were not communicated. The lack of physician notification persisted even as the resident's symptoms worsened, including after a positive COVID test and the onset of gastrointestinal symptoms such as dark stools and decreased intake. Staff interviews revealed a breakdown in communication between therapy, nursing, and management, with several staff members assuming others had notified the physician or were unaware of the resident's previous progress. Ultimately, the resident was transferred to the hospital in a critical state, where she was found to be septic due to COVID and had gastrointestinal bleeding, resulting in a critical hemoglobin level and heart injury.
Failure to Obtain Ordered Labs and Recognize Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to obtain laboratory tests as ordered by the physician and did not ensure effective communication among staff to recognize and respond to a resident's change in condition. The resident, who had a history of stroke, anemia, and hypertension, was admitted for rehabilitation and initially made progress in therapy, including self-feeding, ambulating with assistance, and communicating needs through gestures. Despite a physician's documented plan for specific lab work, no orders were entered or completed for these labs during the resident's stay. In the days leading up to the resident's hospital transfer, multiple staff members—including therapists and nurse aides—observed a significant decline in the resident's functional status. Symptoms included dizziness, lightheadedness, nausea, altered responsiveness, poor appetite, dry mouth, and decreased ability to communicate or participate in therapy. These changes were reported to nursing staff, but there was a breakdown in communication, and the severity of the decline was not recognized or escalated appropriately. Nursing documentation was inconsistent, and some nurses were unaware of the resident's prior progress or the extent of her decline. After testing positive for COVID, the resident did not receive evaluation or medical treatment for her infection or her deteriorating condition until she was transferred to the hospital several days later. At the hospital, she was found to be septic due to COVID infection and had gastrointestinal bleeding resulting in critically low hemoglobin, requiring intensive care and blood transfusions. The lack of timely assessment, failure to follow physician orders for labs, and poor communication among staff contributed to the delay in recognizing and treating the resident's acute medical needs.
Neglect Due to Unauthorized Tube Feeding Cessation
Penalty
Summary
The facility failed to protect residents from neglect when Nurse #1 did not adhere to physician orders for continuous tube feeding for two residents. Nurse #1 independently decided to turn off the tube feeding pumps for Resident #60 and Resident #74, believing their stomachs needed a rest, despite being aware of the physician's orders for continuous feeding. This action deprived the residents of their assessed nutritional needs and was not documented in the residents' medical records. Resident #60, who was readmitted with diagnoses including anoxic brain damage and dysphagia, was dependent on tube feeding. The resident's care plan required continuous tube feeding, but Nurse #1 turned off the feeding pump without notifying the physician. Similarly, Resident #74, who had diagnoses including dysphagia and dementia, was also dependent on tube feeding. Nurse #1 turned off the feeding pump for Resident #74 without physician notification, despite the resident having specific orders for continuous feeding with scheduled downtime for activities of daily living. The facility's Director of Nursing and Registered Dietician were unaware of Nurse #1's actions, which disregarded physician orders. The physician expressed concerns about the residents not receiving necessary calories and nutrients due to the unauthorized cessation of tube feeding. Nurse #1 had a history of disciplinary action for substandard work, and her actions placed the residents at risk of serious harm.
Removal Plan
- Nurse #1 was removed from the facility.
- Nurse #1 was terminated.
- The Director of Nursing assessed the pump settings, dates and times of currently hung feedings, and ensured pumps were on appropriately and feedings were infusing accurately per MD orders.
- The Administrator, DON, and Corporate team will monitor the facility and patient care delivery every shift to ensure that the nutrition and hydration needs of all patients are met based on MD orders.
- The team will utilize newly hired administrative nurse managers, facility management team, and lead CNAs to accomplish shift to shift rounding.
- The DON, ADON, and nurse managers will review findings every morning to ensure appropriate and necessary action has been taken to remedy all identified negative findings.
- The Director will ensure that the MD is notified timely of all discrepancies and plans for correction.
- Education sessions on resident rights, reporting abuse and neglect, and facility policies on abuse, neglect, and exploitation began with all staff.
- No employee will be allowed to work until they have received the education.
- New hires are trained in orientation and education will continue within the facility to ensure understanding of abuse and neglect prevention.
- The Director of Nursing, ADON, and nurse managers will review education sessions daily to ensure that all staff have received it and that no staff members work prior to receiving it.
- Daily ongoing audits of all residents with an order for tube feeding to evaluate the status of the pump status/infusion rate and type of feed per physician order.
Failure to Notify Physician of Tube Feeding Deviations
Penalty
Summary
The facility failed to notify the physician of deviations from prescribed tube feeding orders for two residents, resulting in a deficiency. Nurse #1, who was responsible for the care of these residents, turned off their feeding tube pumps without physician notification or orders. This action was taken based on her belief that the residents' stomachs needed a rest, despite being aware that the tube feedings were ordered to be continuous. This deviation from physician orders deprived the residents of their assessed nutritional needs. Resident #60, who was readmitted to the facility with diagnoses including anoxic brain damage and dysphagia, had a continuous tube feeding order of 60 ml/hr. Observations revealed that the feeding tube pump was turned off for an undetermined amount of time, and Nurse #1 admitted to turning it off for 2 to 3 hours without notifying the physician. Similarly, Resident #74, with diagnoses including dysphagia and dementia, had a tube feeding order for 22 continuous hours. Nurse #1 also turned off this resident's feeding tube pump without physician notification, citing the same reasoning. Interviews with the Registered Dietician and the Director of Nursing confirmed that continuous tube feedings should not be turned off without a physician's order. The physician was not aware of the tube feedings being turned off and expressed concerns about the residents not receiving the necessary calories and nutrients. The facility's failure to ensure physician notification and adherence to prescribed orders for tube feedings led to the identification of this deficiency.
Removal Plan
- The facility confirmed that all residents with enteral feedings, including residents #60 and #74, were resumed and infusing at the rate ordered by the physician.
- Nurse #1 was notified of her failure to follow MD orders.
- The Board of Nursing Complaint Evaluation Tool was completed and reviewed with Nurse #1.
- Nurse #1 was suspended after consultation with the Chief Clinical Officer and the Chief Operating Officer.
- Education sessions were begun with all licensed nurses on consulting and notifying the MD of resident changes and need to alter treatments, and ensuring that MD orders are followed at all times, including orders for enteral feedings.
- The DON and Corporate Clinical Nurse and Chief Clinical Officer conducted the education sessions.
- Education sessions will continue with all staff members until 100% of the licensed nurses have received education.
- The Director of Nursing, ADON, and nurse managers will review education session sign-ins daily to ensure that all staff have received the material effectively and to ensure that no staff members worked prior to receiving it.
- No licensed nurses will be allowed to work until they have received the education.
- The Chief Clinical Officer notified the Facility Nurse Consultant that new licensed nursing staff will be trained in orientation and education will continue within the facility.
- The Chief Clinical Officer notified the Director of Nursing for the need and requirement to complete education prior to employees returning to work.
- The DON notified the hall nurses at the beginning of shifts that an inservice would be held prior to the shift beginning.
- These education sessions will continue until 100% of the licensed nurses have been trained.
Failure to Complete MDS Assessments Timely Due to Staffing Issues
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for eight residents. The assessments for these residents were either incomplete or completed past the regulatory deadline. The residents affected included those with ARDs ranging from mid-August to mid-September, with completion dates extending into late September and early October. This delay in completing assessments was identified during a review conducted on October 3, 2024. The deficiency was attributed to staffing issues within the MDS department. The facility lacked consistent MDS staff, relying on a part-time MDS nurse who worked only twice a week. The Resource Nurse and MDS Nurse #1 confirmed the backlog of incomplete assessments, which was acknowledged by the Administrator. Upon his arrival at the facility on August 30, 2024, the Administrator was aware of the backlog and had taken steps to address it by hiring additional MDS nurses and utilizing remote MDS nurses to assist in completing the overdue assessments.
Failure to Administer Tube Feedings as Ordered
Penalty
Summary
The facility failed to administer tube feedings via a gastrostomy tube as ordered by the physician for three residents, leading to deficiencies in nutrition maintenance. Resident #60, who was severely cognitively impaired and dependent on staff for all activities of daily living, had her feeding tube pump turned off by Nurse #1 without a physician's order. Nurse #1 believed the resident's stomach needed a rest, but this decision was made independently and not documented in the resident's electronic medical record. The Registered Dietician and the Director of Nursing were unaware of this action, and the physician was not notified, which could have contributed to the resident's weight fluctuations. Similarly, Resident #74, who was also severely cognitively impaired and required maximum assistance, had her feeding tube pump turned off by Nurse #1 for the same reason. Despite having a physician's order for scheduled downtime for activities of daily living, Nurse #1 turned off the pump outside of these parameters without notifying the physician or documenting the action. The Registered Dietician noted that the resident's weight had been stable, but the unauthorized action could have impacted the resident's nutritional intake. Resident #341, who had a gastrostomy tube and a tracheostomy, was found to have his feeding pump set at a lower rate than ordered. Nurse #2 admitted to setting the pump based on previous settings without confirming the current physician's orders. The resident's physician emphasized the importance of the ordered feeding rate for wound healing, as the resident had a Stage IV wound. The physician was not informed of any symptoms that would justify a reduced feeding rate, and the Director of Nursing was unaware of any distress that would necessitate such a change.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care to a resident who was dependent on staff for activities of daily living. The resident, who was moderately cognitively impaired and frequently incontinent of urine and stool, required partial assistance with toileting. The care plan for the resident included extensive assistance with toileting needs and monitoring for incontinence, but these interventions were not adequately followed. On the morning of the incident, the resident's roommate reported that the resident's adult brief had not been changed since the previous night. Upon checking, a nurse aide found the resident's brief saturated with urine, indicating a lack of timely incontinence care. The nurse aide assigned to the resident admitted she had not checked the resident for incontinence since the start of her shift, as she was attending to other residents and had planned to address the resident's needs later. Further interviews revealed that the resident's care needs had changed since readmission to the facility, requiring more assistance with feeding and incontinence care. The night shift nurse aide did not recheck the resident for incontinence after an initial change, based on a misunderstanding with the resident's roommate. The Director of Nursing confirmed that the resident should have been checked every two hours due to changes in her health condition.
Failure to Conduct Admission Screening Assessment
Penalty
Summary
The facility failed to conduct and document an admission screening assessment for a resident who was readmitted after hospitalization. The resident, who had non-Alzheimer's dementia and a recent hip fracture, was moderately cognitively impaired and required assistance with daily activities. Upon readmission, there was no documentation in the electronic medical record regarding the resident's cognitive state and functional level. The significant change Minimum Data Set (MDS) assessment was incomplete, and the quarterly MDS indicated the resident's need for assistance with meals, mobility, transfers, and toileting, as well as frequent incontinence. The Director of Nursing (DON) acknowledged that the admission screening assessment should have been completed within 24 to 48 hours of the resident's return. However, the DON did not complete the assessment and failed to communicate the need for it to Nurse #5, who was on the night shift. Nurse #5 was unaware of the requirement to complete the assessment, as it was not communicated to her, and she did not find the assessment packet at the nurse's station. The Clinical Nurse Consultant confirmed that the DON should have initiated the assessment and communicated its necessity to the night shift nurse.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status election was accurately documented throughout the medical record. This deficiency was identified for one of the two residents reviewed for advanced directives. The resident in question was admitted to the facility without a clear order for a code status in the physician's orders from 9/09/24 through 10/01/24. During an interview, a nurse indicated that she believed the resident had a full code status based on a report from another nurse, but upon reviewing the medical record, she could not find a code status order. Instead, she found a hospital note indicating a code with limitations, which she did not understand. The nurse stated that in the absence of a Do Not Resuscitate (DNR) order, the resident would have been treated as full code in an emergency. The Admission Director explained that upon admission, she met with the resident's representative (RR) to discuss advanced directives, and the RR requested a DNR order, which was documented and signed. However, the Admission Director was unaware of the follow-up actions taken by the charge nurse, who was new and no longer worked at the facility. The Director of Nurses (DON) confirmed that the resident did not have a DNR order in place until after the surveyor identified the concern, indicating a lapse in the facility's process for ensuring accurate documentation of code status orders.
Failure to Complete Timely MDS Assessment for New Admission
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) assessment within the required timeframe for a newly admitted resident. The resident was admitted on a specific date, and their admission MDS, which was due, had not been completed by the time of review. Interviews with staff revealed that the facility had been without full-time MDS staff for approximately three months, leading to a backlog of incomplete assessments. The MDS Nurse acknowledged the delay and stated that efforts were being made to catch up on the pending assessments. The Administrator was aware of the issue and confirmed that additional MDS nurses had been hired to address the backlog.
Failure to Conduct PASRR Level 2 for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of mental disorders received a Level 2 Preadmission Screening and Resident Review (PASRR) after admission. The resident, who was admitted with schizophrenia and bipolar disorder, had a PASRR Level 1 assessment indicating they did not meet the federal definition for mental illness and mental retardation. Despite this, the resident was prescribed Haloperidol for paranoid schizophrenia, and their care plan included the use of antipsychotic medications. The admission Minimum Data Set (MDS) assessment noted that the resident was not considered by the state Level II PASRR process to have a serious mental illness. The deficiency was identified during a review of records and staff interviews, revealing that the Social Worker had not reviewed the resident's diagnoses upon admission and had only initiated the PASRR Level 2 screening process after an inquiry was made. The Clinical Nurse Consultant and the Administrator acknowledged that a PASRR Level 2 should have been submitted due to the resident's diagnoses. The Social Worker explained that the PASRR Level 1 determination was only valid for thirty days from hospitalization, and the oversight was discovered after the resident had been in the facility for some time.
Failure to Create Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for a resident diagnosed with nontraumatic intracerebral hemorrhage and dysphagia. The resident, who was unable to speak, rarely understood others, and could not participate in assessments, also had an unhealed Stage IV wound. Despite these significant medical needs, there was no documentation of a baseline care plan in the electronic medical record. The Director of Nursing confirmed that the baseline care plan, which should have been completed by the charge nurse within 48 hours of admission, was not done.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for 8 consecutive hours daily, 7 days a week, as required by regulations, for three specific dates within a 60-day review period. A review of the facility's daily nurse staffing totals and nursing clock-in sheets for August and September 2024 revealed that there was no RN present on 8/3/24, 8/18/24, and 9/15/24. During an interview, the Chief Clinical Officer confirmed the absence of an RN on these dates, citing a lack of available RNs despite offering overtime and bonuses to existing staff. The facility's schedule only included licensed practical nurses (LPNs) and medication aides on those days. The Administrator was unaware of the RN staffing deficiency on the specified dates.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist for a resident who was reviewed for unnecessary medications. The resident, who was admitted with diagnoses including dementia and Alzheimer's disease, was prescribed Quetiapine Fumerate, an antipsychotic medication. The Consultant Pharmacist conducted monthly Medication Regimen Reviews and recommended an Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for side effects associated with the antipsychotic medication. However, there was no written response to these recommendations, and no AIMS assessment was documented in the resident's electronic medical record. Interviews with the Consultant Pharmacist and nursing staff revealed communication lapses regarding the pharmacy's recommendations. The Consultant Pharmacist had identified concerns about AIMS assessments not being completed and had communicated these concerns to the facility's administration. Despite this, the Interim Director of Nursing (DON) and the new DON both failed to ensure the AIMS assessment was conducted. The Interim DON could not recall informing the nursing staff to complete the assessment, and the new DON acknowledged receiving the pharmacy recommendations but did not address them. This inaction resulted in the failure to monitor the resident for potential side effects of the antipsychotic medication.
Expired Insulin Aspart Flex Pen Not Discarded
Penalty
Summary
The facility failed to discard an expired insulin aspart flex pen from one of the medication carts, specifically the 300-hall medication cart. During an observation, a flex pen with a label indicating it was opened on 8/23 was found, despite the manufacturer's recommendation to discard it 28 days after opening. The expiration date on the pen was 8/31/26, but it should have been discarded by 9/19/24. Medication Aide #1, who was present during the observation, was unaware of the expiration period for the insulin aspart flex pen. The Director of Nursing (DON) later confirmed the oversight and removed the expired insulin aspart flex pen from the cart. The DON admitted to checking the cart for expired medications earlier in the week but could not explain why the expired pen was still present. The Chief Clinical Officer stated that medication carts are regularly checked for expired medications by nursing staff, pharmacy staff, and nursing administration, but the expired medication was not removed as required.
Deficient Pest Control Program Leads to Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in mice sightings and evidence of mice presence in two of the facility's halls. Residents who were cognitively intact reported seeing mice and finding mouse droppings in their rooms. One resident on the 300 hall reported seeing mice as recently as a week prior to the interview. Another resident on the 200 hall allowed an inspection of her dresser, where small black pellets, identified as mouse droppings, were found near an open package of clean briefs. A third resident, also on the 200 hall, reported ongoing issues with mice for the past year, including finding droppings in her dresser and hearing mice. Glue traps and a metal live mouse trap were observed in her room. The facility's pest control treatment logs indicated treatments for rats and mice in July, September, and October of 2023, but there was no documentation of treatments since October. The Maintenance Supervisor confirmed that exterminators had visited the facility since October but had not always documented their visits. He acknowledged the increased presence of mice this year and confirmed the interventions placed in the resident's room. Staff reported complaints of mice verbally to the Maintenance Supervisor, but there was not always an official work request. The administrator confirmed reports of mice in the facility, with staff and residents continuing to report sightings.
Failure to Report Allegations to APS
Penalty
Summary
The facility failed to report allegations of abuse and neglect to Adult Protective Services (APS) for three residents. The first incident involved a resident who alleged verbal abuse and intimidation by a staff member. The facility became aware of this incident and notified local law enforcement but did not notify APS, as indicated by the blank notification area in the investigation report. The second incident involved a resident who alleged neglect resulting in skin breakdown. Similar to the first incident, the facility notified local law enforcement but failed to notify APS, with the investigation report again showing a blank notification area. The third incident involved another resident who alleged neglect due to not receiving hygiene and incontinent care for over six hours. The facility was aware of this allegation and notified local law enforcement but did not notify APS, as reflected in the investigation report. During an interview, the Administrator admitted to not notifying APS, stating she was unaware of the requirement and believed only local police needed to be informed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 80 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dunn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harnett Woods Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Liberty Healthcare Services Of Golden Years Nursin | 7.7 mi | ★★★★★ | 7 | 0 |
| Liberty Commons Nursing & Rehabilitation Center Of | 8.4 mi | ★★★★★ | 12 | 0 |
| Lillington Health And Rehabilitation Center | 10.8 mi | ★★★★★ | 0 | 0 |
| Emerald Health & Rehab Center | 12.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Carrolton Of Dunn.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.