Above average — CMS composite of the measures below.
The next survey window likely opens 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 Nash during CMS and state inspections, most recent first.
Kitchen sanitation and dish-handling practices were deficient when the fryer, kitchen walls, and an air conditioner unit were not cleaned for extended periods, leaving visible grease, food debris, and residue on equipment and surfaces. In addition, large numbers of meal trays, juice cups, pans, and plates were repeatedly observed stacked with wet nesting instead of being fully air dried before storage or use, despite staff acknowledging that all dishes and trays must be air dried. Staff interviews revealed gaps in the cleaning schedule, inconsistent adherence to air-drying procedures, and workload and training issues contributing to these unsanitary conditions.
A resident with hemiplegia, vascular dementia, generalized weakness, osteoarthritis, and chronic pain, who was non‑ambulatory and fully dependent for bathing and repositioning, was being given a bed bath by one NA. The NA raised and moved the bed away from the wall but failed to ensure the bed wheels were locked before rolling the resident, causing the bed and resident to move together and leaving much of the resident’s body unsupported off the bed. Two additional NAs responded and, due to the resident’s weight, the moving bed, and limited space created by a nearby nightstand and geri‑chair, were unable to return the resident safely to the bed and instead lowered her to the floor face down with her right arm underneath her. The resident was later found to have a closed head injury, a right shoulder dislocation, and a right humerus fracture, and the DON acknowledged that the bed should have been locked and that the resident should have had a two‑person assist for care.
The facility did not provide written advance directive information or opportunities to formulate advance directives for 10 residents, despite having physician orders for code status. Staff interviews revealed discussions were limited to code status, and the Social Worker was unaware of the requirement to educate on advance directives.
The facility failed to implement its infection prevention and control program, as observed in multiple instances. A unit manager did not wear a gown or perform hand hygiene during tracheostomy care for a resident on Enhanced Barrier Protection. A wound treatment nurse did not change gloves or perform hand hygiene between tasks while treating a resident's pressure ulcers. Additionally, a nurse aide carried uncontained dirty linen and did not perform hand hygiene between resident rooms. These actions were contrary to the facility's established policies.
The facility failed to notify the Ombudsman of hospital transfers for two residents, with delays of several months. The Social Worker responsible for notifications admitted to forgetting to send them, despite being educated on the requirement upon hire.
A facility failed to ensure a physician's order for the size and frequency of changing an indwelling urinary catheter for a resident with severe cognitive impairment. The resident had a 16 French catheter, but the electronic health record lacked the updated order from a urology consultation. Staff interviews revealed a communication breakdown in entering orders into the electronic medical record.
A facility failed to obtain physician orders for a resident's tracheostomy oxygen and FiO2 settings after hospital readmission. The resident, with acute respiratory failure and pneumonia, was on 5 liters of oxygen and 35% FiO2, but no orders were documented. Staff interviews revealed expectations for order confirmation, but the Unit Manager confirmed the absence of orders. The Respiratory Therapist noted the FiO2 was for humidification, yet orders were needed. The previous DON stated the oversight should have been caught in clinical meetings.
The facility failed to discard expired medications in two medication carts. An opened bottle of Simethicone 80 mg with an expired date and Moxifloxacin 0.5% eye drops past the discard date were found. Medication aides acknowledged the oversight, and the Interim DON and Administrator confirmed that staff were responsible for checking and removing expired medications.
A facility failed to document wound care treatment for a resident, as required by physician orders. The Treatment Administration Records (TAR) had blanks on multiple dates where staff should have indicated if treatment was administered or not. Interviews with nursing staff revealed a lack of awareness and memory regarding the missing documentation. The Unit Manager, DON, and Administrator confirmed the requirement for documentation of all care provided.
A facility failed to maintain a clean environment in a resident's room, as evidenced by a dirty oxygen concentrator and dried substances on the floor. Despite daily cleaning protocols, the Housekeeping Manager had not checked the room, and Housekeeper #1 admitted to not cleaning the room properly on multiple occasions. The Interim Administrator confirmed that rooms were to be cleaned daily.
Unsanitary Kitchen Equipment and Improper Air Drying of Dishes and Trays
Penalty
Summary
Failure to maintain sanitary food service conditions occurred when kitchen equipment and surfaces were not properly cleaned and when dishes and trays were stacked while still wet. During a kitchen observation with the Dietary Manager, the fryer was found with dark brown liquid and food crumbs covering the bottom and inside walls; the Dietary Manager stated it was last cleaned two weeks prior, and records showed the last documented cleaning was on 12/25/25. Additional observations showed a yellow, sticky substance on the wall behind the bread rack, around a bulletin board, and below an air conditioner, with the Dietary Manager acknowledging the walls had probably not been cleaned in over a month and that wall cleaning was not on the current schedule. The air conditioner wall unit above a preparation table had a black/brown substance inside the unit and over the filter spaces, and the Dietary Manager reported it had last been cleaned during the previous summer and was also not on the cleaning schedule. The Administrator confirmed that cleaning of the fryer, walls, and air conditioner unit should be done in a timely, consistent manner. Multiple observations on different days showed that meal trays, cups, pans, and dishes were stacked with “wet nesting” instead of being fully air dried before storage or use. Over seventy meal trays on the tray line, fifty-five plastic juice cups stacked in pairs under the tea machine, four full-service pans on the cook’s clean cart, and ninety-one plates behind the tray line were all observed with wet nesting, despite the Dietary Manager stating that all items should be air dried and normally left on racks to dry. The Dietary Manager attributed some of the problem to a newly hired cook/dietary aide still in training and later stated that staff were moving too fast during dishwashing and did not allow enough time for air drying. On a subsequent observation, nine full pans and seventy-three meal trays were again found with wet nesting; the dietary aide responsible for air drying trays acknowledged that dishes and silverware needed to be air dried but suggested residual wetness might have come from her wet gloves, while another staff member responsible for pots and pans stated he knew they should be air dried but had too many items and not enough room to dry them all. The Administrator stated that all dishes and pans should be air dried prior to use or storage.
Improper Bed Positioning and Single‑Staff Assist During Bed Bath Leads to Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during personal care, resulting in a resident sustaining a closed head injury and a right shoulder dislocation with a right humerus fracture. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, vascular dementia, generalized muscle weakness, osteoarthritis, and chronic pain managed with scheduled acetaminophen. She was non‑ambulatory, dependent on staff for ADLs, and weighed 241 pounds. Her care plan identified risks related to immobility, self‑care deficits, and chronic pain, with interventions including total dependence on staff for bathing and turning/repositioning in bed as necessary. On the morning of the incident, the assigned nurse aide entered the resident’s private room to provide a bed bath. The bed was initially positioned with the left side against the wall and was raised to the aide’s waist height. The aide reported locking the bed, then unlocking it to move it away from the wall to gain access from both sides, and believed she had re‑locked it afterward. As she stood on the left side of the bed and attempted to roll the resident toward the right, both the bed and the resident began to move because the bed wheels were not actually locked. The resident’s head, shoulders, and legs were left hanging off the bed with most of her weight unsupported, while the aide held her by the torso and yelled for help. Two additional nurse aides responded and attempted to assist. One aide held the resident’s legs, another held her head and arm, and they noted that the resident’s leg was stuck between the geri‑chair and the bed and that the bed continued to move, with limited space to maneuver due to the proximity of the nightstand and geri‑chair to the bed. The three aides were unable to lift or push the resident back onto the bed and slowly lowered her to the floor, where she ended up face down with her right arm underneath her. Staff accounts indicated the resident may have hit her head on the nightstand, and she complained of head and right shoulder pain. When nursing staff arrived, the resident was found face down on the floor with a large knot on her forehead and complaints of right arm pain. She was subsequently sent to the ED, where she was diagnosed with a fall, closed head injury, right shoulder dislocation, and right humerus fracture. The Director of Nursing later stated that the aide should have ensured the bed was locked and that, given the resident’s size and physical limitations, she should have been assisted by two staff during care.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written advance directive information and an opportunity to formulate an advance directive for 10 out of 33 residents reviewed. These residents had various medical conditions, including heart failure, chronic obstructive pulmonary disease, diabetes, kidney failure, and a history of stroke. Despite having physician orders for either full code or do not resuscitate status, there was no documentation in their medical records indicating that they were educated about or given the opportunity to formulate an advance directive. Interviews with the facility's staff, including the Administrator, Admissions Director, and Social Worker, revealed that discussions with residents and their responsible parties were limited to code status. The Social Worker, who was new to the position, was unaware of the requirement to provide education on advance directives beyond code status. This lack of comprehensive discussion and documentation regarding advance directives led to the identified deficiency.
Infection Control Deficiencies in PPE and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to its infection prevention and control program policies during the care of residents, leading to multiple deficiencies. Unit Manager #2 did not wear a gown and failed to perform hand hygiene between glove changes while providing tracheostomy care to a resident on Enhanced Barrier Protection (EBP). Despite the availability of personal protective equipment (PPE) and prior education on its use, Unit Manager #2 neglected to don a disposable gown and did not perform hand hygiene after obtaining additional supplies from a drawer, which was required by the facility's policies. The Wound Treatment Nurse also failed to follow proper infection control procedures during the treatment of a resident's pressure ulcers. The nurse did not perform hand hygiene between glove changes and did not change gloves when transitioning from dirty to clean tasks. This oversight occurred despite the nurse's acknowledgment of the need for hand hygiene and the facility's policy requiring it. The nurse had received education on proper PPE use and handwashing but did not adhere to these protocols during the observed treatment. Additionally, Nurse Aide #1 was observed carrying uncontained dirty linen in the hallway and failed to perform hand hygiene after removing gloves and before entering another resident's room. The aide admitted to not having plastic bags available and was unaware of the lapse in hand hygiene. The Director of Nursing confirmed that the aide should have had plastic bags, removed gloves, and performed hand hygiene between resident rooms, as per the facility's infection control policies.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman in writing of resident transfers to the hospital for two residents reviewed for hospitalization. Resident #2 was transferred to the hospital on two occasions, once on 7/02/24 and again on 8/12/24, for evaluation of changes in mental status. In both instances, the Ombudsman was not notified of these transfers until 10/23/24, several months after the events occurred. Similarly, Resident #42 was transferred to the hospital on 7/21/24 and 8/20/24 for evaluation, and the Ombudsman was also not notified until 10/23/24. Interviews revealed that the facility's Social Worker, who started in April 2024, was responsible for sending transfer and discharge notifications to the Ombudsman. However, she admitted to forgetting to send the information monthly, resulting in a lack of notification for the past six months. The Interim Administrator confirmed that the Social Worker had been educated on this responsibility upon hire but was unsure why the notifications were not sent.
Failure to Update Catheter Orders in Medical Records
Penalty
Summary
The facility failed to ensure that there was a physician's order in place for the size and frequency of changing an indwelling urinary catheter for a resident with severe cognitive impairment and a history of kidney and ureter disorder. The resident was admitted with an indwelling urinary catheter and was dependent on staff for toileting. Although a care plan was in place to monitor for signs of infection, the facility did not have an updated order for the catheter size and change frequency as recommended by a urology consultation. The deficiency was identified when it was observed that the resident had a 16 French indwelling urinary catheter, but the electronic health record did not reflect the urology consultation's order to change the catheter monthly. Interviews with staff revealed a breakdown in communication and responsibility for entering the orders into the electronic medical record. The Unit Manager was responsible for entering the orders, but the Medical Records Clerk was out during the relevant period, leading to a lapse in updating the resident's medical records with the new orders.
Failure to Obtain Physician Orders for Tracheostomy Oxygen Settings
Penalty
Summary
The facility failed to obtain a physician order for the oxygen and fraction of inspired oxygen (FiO2) settings for a resident with a tracheostomy. The resident, who had been readmitted to the facility with acute respiratory failure, pneumonia, and a tracheostomy, was observed to have an oxygen concentrator set to 5 liters and FiO2 set to 35%. Despite these settings being in place since the resident's return from the hospital, no physician orders were documented for these settings. The care plan indicated the resident required 5 liters of oxygen with 28% humidity, but this was not reflected in the physician orders. Interviews with facility staff, including the Unit Manager and Nurse Practitioner, revealed that the settings were expected to be confirmed and signed by a provider upon the resident's return. However, the Unit Manager, responsible for entering the orders, confirmed that no such orders were in place. The Respiratory Therapist noted that the FiO2 setting was primarily for humidification, but acknowledged that orders were necessary. The previous Director of Nursing indicated that the orders should have been identified and confirmed during clinical meetings, but was unable to explain why the orders were missed.
Expired Medications Not Discarded in Medication Carts
Penalty
Summary
The facility failed to properly dispose of expired medications in two of the four medication carts observed during a survey. On the 700 Hall medication cart, an opened bottle of Simethicone 80 mg was found with an expiration date of July 2024, indicating it was expired at the time of observation. Medication Aide #2 acknowledged that the medication should have been discarded and stated that the medication aide or nurse assigned to the cart was responsible for checking for expired medications each shift. Similarly, on the 200 Hall medication cart, an open bottle of Moxifloxacin 0.5% eye drops was found with a prescription filled date of September 20, 2024, and an open date of the same day. The manufacturer's package insert specified that any unused ophthalmic moxifloxacin should be discarded 30 days after opening to prevent further eye infections. Medication Aide #3 confirmed that the medication should have been discarded after the resident completed the prescribed doses. The Interim Director of Nursing and Interim Administrator also stated that the medication aides and nurses were responsible for checking carts for expired medications and that expired medications should be removed immediately.
Failure to Document Wound Care Treatment
Penalty
Summary
The facility failed to properly document physician orders for wound care treatment for a resident, identified as Resident #94. The Treatment Administration Records (TAR) for this resident contained blanks where staff were supposed to indicate whether the treatment was administered or not, along with an explanation if it was not administered. The physician orders for Resident #94 included cleansing the right lateral ankle and applying calcium alginate with silver cover, and cleansing the left lateral ankle with Santyl ointment. However, there were multiple dates where the documentation was missing, specifically on 10/3, 10/5, 10/6, 10/10, 10/13, 10/19, and 10/20. Interviews with nursing staff revealed a lack of awareness and memory regarding the missing documentation. Nurse #1, who regularly provided care to Resident #94, was unaware of the missing sign-offs on the TAR. Nurse #2, who provided wound care on 10/19, could not recall why the treatment was not documented. The Unit Manager and the Director of Nursing confirmed that staff are required to document all care provided, including instances of resident refusal. The Administrator reiterated the requirement for documentation of care provided to residents.
Failure to Maintain Clean and Sanitary Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in one of the resident rooms, as evidenced by observations of an oxygen concentrator with a dried beige substance on its top and front, and multiple dime-sized brown hardened substances on the floor near the feeding tube pole and resident bed. These observations were made over three consecutive days, indicating a persistent issue with cleanliness in the room. The Housekeeping Manager confirmed that the oxygen concentrator should have been wiped down daily and the floor mopped every day, but acknowledged that he had not checked the room to ensure proper cleaning was completed. Housekeeper #1, who was assigned to the room on multiple days, admitted to not being able to remove the dried substance from the floor and failing to report this issue to the manager. Additionally, she did not clean the room on one occasion because the nurses were attending to the tube feeding and did not return later to complete the cleaning. On another day, she informed the resident she would return to clean but had not done so by the time of the interview. The Interim Administrator confirmed that resident rooms were expected to be cleaned daily, highlighting a lapse in adherence to the facility's cleaning protocols.
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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.
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Nursing homes near Rocky Mount
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lodge At Rocky Mount Health And Rehabilitation | 1.8 mi | ★★★★★ | 3 | 0 |
| Rocky Mount Rehabilitation Center | 1.8 mi | ★★★★★ | 15 | 0 |
| Autumn Care Of Nash | 5.2 mi | ★★★★★ | 1 | 0 |
| Edgecombe Health Center By Harborview | 17 mi | ★★★★★ | 0 | 0 |
| Tarboro Health And Rehabilitation Llc | 17.1 mi | ★★★★★ | 0 | 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.