Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Carrolton Of Fayetteville during CMS and state inspections, most recent first.
The facility did not ensure proper removal of debris and closing of dumpster doors, as observed with two dumpsters having trash such as used gloves, napkins, and lint in front of them, and one dumpster door left open. The area was the responsibility of the dietary department, but all departments used the dumpsters, and there was no formal cleaning schedule in place.
A resident with severe cognitive impairment was administered psychotropic medications without documented consent from the Responsible Party. Medical records lacked evidence of a discussion about risks, benefits, or alternative treatments, and staff interviews confirmed that consent was not obtained at admission as required.
A resident with moderate cognitive impairment and a legal guardian was not informed of the right to accept or refuse treatment or to formulate an advance directive at admission. The social worker did not complete the required documentation or follow up appropriately with the responsible party, resulting in a lack of timely communication and documentation of advance care planning rights.
A resident was readmitted with new diagnoses of unspecified psychosis and a psychotic disorder with hallucinations, but the required PASRR Level II screening was not completed. The Social Worker responsible for PASRR screenings acknowledged the oversight, and the DON confirmed that such screenings are expected for residents with mental health diagnoses.
A resident admitted with bipolar disorder and prescribed risperidone was not submitted for a PASRR Level II screening, despite having a PASRR Level I determination. The Social Worker responsible for the screening process acknowledged the oversight, and the Administrator confirmed the resident should have been screened due to the diagnosis.
A resident with Alzheimer's and severe cognitive impairments experienced multiple skin tears and a bruise, but the responsible party was not notified as required by facility protocol. Nursing staff acknowledged the oversight, and the facility's leadership confirmed the expectation for notification.
A resident in an LTC facility missed three doses of Lovenox due to a transcription error in the physician's order, which incorrectly stated to stop the medication when the INR was less than 2.0 instead of greater than 2.0. The resident, who had acute respiratory failure and a replaced heart valve, continued to receive Warfarin, and the physician confirmed no harm resulted from the missed doses. The error was identified through staff interviews and record reviews.
A facility failed to thoroughly investigate an abuse allegation after a resident claimed a nursing assistant hit him. The investigation was limited to the resident's hall, and no evidence of abuse was found. The nursing assistant was suspended for one day and then allowed to return to work.
A staff member at the facility took money from a resident's pants pocket without consent while the resident was in bed. The resident, who was cognitively intact, reported the incident, and the staff member admitted to the theft and was terminated. The facility conducted an investigation and took steps to prevent recurrence, including staff education and reimbursement to the resident.
A resident with a wound infection did not receive a scheduled dose of IV antibiotic therapy due to an oversight by a nurse who was occupied with another resident. The interim DON confirmed the error and initiated a Plan of Correction, including staff education and daily audits of MARs and TARs to prevent future occurrences.
Improper Disposal and Management of Dumpster Area
Penalty
Summary
The facility failed to ensure proper disposal and management of garbage and refuse in the dumpster area. During an observation, two out of three dumpsters had debris, including used gloves, used napkins, and a large pile of lint from a washing machine, in front of them. Additionally, one dumpster had its door left open. The Dietary Manager confirmed that his department was responsible for the area but noted that all departments used the dumpsters, and staff were supposed to clean the area daily. The Administrator acknowledged that trash was collected three times a week, but debris was often left behind and the dumpster doors would sometimes remain open. There was no formal cleaning schedule for the dumpster area; instead, staff were expected to pick up items if they noticed them.
Failure to Obtain Consent for Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain and document consent from a resident's Responsible Party (RP) for the use of psychotropic medications. The resident was admitted with diagnoses including dementia with behavioral disturbance, depression, and a history of stroke. Physician orders were in place for mirtazapine and quetiapine fumarate to be administered for depression and behavioral disturbances, respectively. The resident was assessed as severely cognitively impaired and had received both an antidepressant and an antipsychotic during the review period. A review of the resident's medical records revealed no documentation of consent, discussion of risks versus benefits, or alternative treatment options with the RP regarding the use of psychotropic medications. Interviews with facility staff, including the DON, Unit Manager, and Administrator, confirmed that consent should have been obtained at admission but was missed. Staff indicated that obtaining consent is the responsibility of the admitting nurse, unit manager, and all licensed nurses entering the orders, and the omission was attributed to the timing of the admission.
Failure to Inform Resident or Responsible Party of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident and/or their Responsible Party (RP) of the right to accept or refuse medical or surgical treatment and to formulate an advance directive. The resident in question was admitted with a legal guardian as RP and had a physician order indicating full code status. The social service history and initial assessment form, which included an advanced care planning section, was not completed at the time of admission. The resident's quarterly MDS assessment indicated moderate cognitive impairment, making it especially important for the RP to be informed of these rights. A review of the medical record showed no documentation that the resident or RP was informed of the right to refuse treatment or to create an advance directive. The Social Worker (SW) stated that she typically discussed advance directives during admission but had only attempted to contact the RP by phone and had not sent a certified letter after unsuccessful attempts. The SW eventually reached the RP and discussed advance care planning, but this occurred well after admission and was not documented in a timely manner. Both the DON and Administrator confirmed that the SW should have followed up and ensured the discussion and documentation took place as part of the admission process.
Failure to Complete PASRR Screening for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident who was readmitted with newly identified mental health diagnoses, including unspecified psychosis not due to a substance or known physiological condition and psychotic disorder with hallucinations due to a known physiological condition. Upon review of records and staff interviews, it was found that the resident's admission Minimum Data Set (MDS) indicated severe cognitive impairment and listed relevant psychiatric diagnoses, but the state Level II PASRR process had not been initiated to assess for serious mental illness or intellectual disability. The Social Worker, who was responsible for PASRR screenings, confirmed that a Level II PASRR should have been completed at the time of readmission with the new diagnoses. The Director of Nursing also stated that the Social Worker was expected to complete PASRR Level II screenings for all residents with mental health diagnoses.
Failure to Apply for PASRR Level II Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to apply for a Preadmission Screening and Resident Review (PASRR) Level II screening for a resident who was admitted with a diagnosis of bipolar disorder. The resident had a PASRR Level I determination letter, and upon admission, was prescribed risperidone, an antipsychotic medication, for psychosis. Despite these indicators, the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, which led to the oversight in not applying for a PASRR Level II screening. Interviews with facility staff revealed that the Social Worker (SW) was responsible for initiating the PASRR Level II screening process when a resident was admitted with a psychiatric diagnosis or psychotropic medication. However, the SW did not submit the necessary application for the resident in question, acknowledging it as an oversight. The Administrator confirmed that the resident should have been screened for a PASRR Level II due to the bipolar disorder diagnosis and identified the SW as the person responsible for this task.
Failure to Notify Responsible Party of Resident Injuries
Penalty
Summary
The facility failed to inform the responsible party (RP) of skin tears and bruises for one resident, identified as Resident #150, who was admitted with diagnoses including Alzheimer's disease, hypothyroidism, and hypertension. The resident had severe cognitive impairments affecting daily decision-making. The deficiency was identified through record reviews and staff interviews, revealing that the RP was not notified of multiple skin tears and a bruise observed on the resident between December 2023 and May 2024. Specifically, skin tears were noted on the resident's left hand, right cheek, and face, and a bruise was observed on the left knee. Interviews with nursing staff indicated that the facility's protocol required notifying the RP and completing an incident report for such injuries, but this was not followed. Nurses involved acknowledged the oversight and expressed intentions to adhere to the protocol in the future. The Assistant Director of Nursing and the Director of Nursing were unaware of the reasons for the failure to notify the RP, despite the expectation that staff would communicate any changes in the resident's condition. The facility's administrator also confirmed the expectation for RP notification and indicated that staff would be re-educated on this requirement.
Medication Transcription Error Leads to Missed Doses
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors due to an incorrectly transcribed admission order for a resident. The physician's order was to stop Lovenox, a medication used to prevent blood clots, when the INR was greater than 2.0. However, the order was transcribed incorrectly to stop Lovenox when the INR was less than 2.0. This error affected one resident who was readmitted to the facility with acute respiratory failure and other comorbidities, including a replaced heart valve. The resident's INR was 1.4, indicating that the Lovenox should not have been stopped according to the physician's original order. Despite this, the medication was held for three days, resulting in missed doses. The resident continued to receive Warfarin as directed, and the physician noted that the missed doses of Lovenox did not contribute to any harm to the resident's well-being. Interviews with the staff revealed that the transcription error was made by a nurse who was subsequently removed from the admissions position. The facility identified that all residents with Lovenox orders had the potential to be affected by similar transcription errors, although no other discrepancies were found upon review.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident who claimed that a nursing assistant hit him in the stomach. The initial report indicated that the resident identified the alleged perpetrator, and the facility suspended the nursing assistant and began an investigation. However, the investigation was limited to interviews and skin assessments of residents on the same hall as the alleged victim, and it did not expand to other areas where the nursing assistant had worked prior to the incident. The facility's investigation concluded that the allegation was unsubstantiated based on the lack of physical evidence and the resident's history of manipulative and attention-seeking behaviors. The Director of Nursing (DON) and the Chief Clinical Officer were involved in the investigation, with the Chief Clinical Officer taking over after the initial interview with the resident. The investigation included interviews with alert and oriented residents and skin assessments of residents with lower cognitive scores on the same hall. The facility did not find any signs of abuse or corroborating statements from other residents. The nursing assistant was allowed to return to work after one day of suspension. The Administrator confirmed that the investigation did not extend to other areas of the facility where the nursing assistant had previously worked. The decision to limit the investigation was based on the absence of positive findings from the initial interviews and assessments. The facility believed that suspending the nursing assistant immediately after the allegation removed any immediate threat, and they deemed the allegation unsubstantiated due to inconsistencies in the resident's story and the lack of supporting evidence from other residents and skin assessments.
Misappropriation of Resident's Property by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a staff member took money from a resident's pants pocket without consent. The incident involved a resident who was cognitively intact and had been admitted with orthopedic conditions. The resident was lying in bed with his head covered when a floor technician entered the room and took money from his pocket. The resident identified the staff member and reported the incident to the facility's social worker and director of nursing, who then notified the police. However, the resident chose not to press charges. The floor technician admitted to taking the money and was subsequently terminated from employment. The facility conducted an investigation, including interviews with the resident and staff members. The resident reported feeling safe in the facility and stated that this was the first time such an incident had occurred. The police were involved, but no charges were pressed by the resident. The facility reviewed the incident and took steps to address the issue, including reimbursing the resident for the stolen money. The director of nursing and social worker conducted further investigations to ensure no other residents were affected. Staff were educated on the misappropriation of property, and the facility implemented measures to prevent recurrence. The incident was also discussed in the facility's Quality Assurance and Performance Improvement committee meetings.
Missed Dose of IV Antibiotic Therapy
Penalty
Summary
The facility failed to ensure that Resident #4 received a scheduled dose of intravenous (IV) antibiotic therapy. Resident #4, who was admitted with an infection and inflammatory reaction due to a wound infection, had a physician's order for Piperacillin-Tazobactam to be administered every 8 hours. On the specified date, the 2:00 PM dose was missed by Nurse #1, who was occupied with another resident at the time and overlooked the medication administration. This oversight was confirmed through a telephone interview with Nurse #1, who acknowledged the error and stated that she had been educated on the importance of administering medications as ordered following the incident. The interim Director of Nursing (DON) became aware of the missed dose the following day and confirmed the error through a review of the Medication Administration Record (MAR). The DON spoke with Nurse #1, who admitted to missing the dose due to being preoccupied with another resident. The DON then initiated a Plan of Correction, which included assessing Resident #4, notifying the family and physician, and ensuring that subsequent doses were administered as ordered. The DON also educated all nursing staff on the importance of medication administration and increased communication between nurses and medication aides. The Ombudsman was informed of the missed dose and confirmed that the family of Resident #4 was aware of the incident. The family did not express concerns about any adverse effects from the missed dose but was concerned that it had occurred. The facility conducted an audit of all residents on IV therapy to ensure no other doses were missed and implemented daily audits of MARs and Treatment Administration Records (TARs) to prevent future occurrences.
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What surveyors actually found near you
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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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Green Health And Rehabilitation | 2.2 mi | ★★★★★ | 3 | 0 |
| Carolina Rehab Center Of Cumberland | 3.1 mi | ★★★★★ | 11 | 0 |
| Haymount Rehabilitation & Nursing Center, Inc. | 4.1 mi | ★★★★★ | 0 | 0 |
| Woodlands Nursing & Rehabilitation Center | 5.2 mi | ★★★★★ | 0 | 0 |
| Highland House Rehabilitation And Healthcare | 5.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.