Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Plymouth during CMS and state inspections, most recent first.
The facility experienced recurring sewage backups in the 200 and 500 halls due to corroded pipes, causing toilets to overflow and creating a hazardous environment. Residents and staff reported frequent backups, with maintenance and plumbers confirming the need for pipe replacement. Despite awareness and recommendations, only partial replacements were made, leading to ongoing issues.
The facility experienced recurring sewage backups in the 200 and 500 hallways, causing water to pool on floors and creating slip hazards. Staff and residents reported that the issue occurred multiple times a month, particularly during heavy rain, leading to toilets overflowing and water entering resident rooms. Despite measures like mopping and wet floor signs, the problem persisted, posing a safety risk.
The facility's governing body failed to replace corroded sewer lines, resulting in frequent sewage backups on the 200 and 500 halls. The Maintenance Director reported ongoing issues with overflowing toilets and sewage in the hallways, which had been a problem for seven years. Plumbers confirmed the pipes were severely corroded and recommended replacement, but only partial repairs were made due to cost concerns. The Administrator was aware of the issue but attributed it to residents flushing inappropriate items.
A facility failed to develop a comprehensive care plan for a resident with a g-tube, which was necessary for nutrition, hydration, and medication. The MDS Nurse admitted to not including the g-tube in the care plan without providing a reason. The DON and Administrator were unaware of the omission, acknowledging that a care plan should have been in place.
A resident with a g-tube did not have a physician's order for site care, leading to nurses providing care based on past experience. The Wound Care Nurse and DON acknowledged the need for a formal order, revealing a lapse in professional standards.
The facility failed to manage enteral feeding and g-tube care properly for two residents. A resident's enteral feeding bags and syringe were not labeled, and the feeding machine was set incorrectly. Another resident received unauthorized free water flushes through a g-tube. Staff admitted to not following protocols, and the DON acknowledged the need for proper training and adherence to physician orders.
A nurse in an LTC facility failed to follow infection control protocols during tracheostomy care for a resident with cognitive impairment and a history of stroke. The nurse did not perform hand hygiene or don sterile gloves after handling soiled items before placing new sterile items, risking bacterial contamination. The breach was confirmed by the Infection Preventionist and Medical Director.
A facility failed to maintain proper documentation and monitoring for a resident with End Stage Renal Disease requiring hemodialysis. The resident's weights were not recorded since November 2024, and dialysis communication forms were missing. Staff were unaware of the discrepancies, and the resident had been hospitalized for fluid overload after stopping dialysis for several months. Despite resuming dialysis, the facility did not update weight records, relying on outdated information.
The facility failed to attempt alternatives before installing side rails for three residents. A resident with hemiplegia, another with end-stage renal disease, and a third with osteomyelitis all had side rails installed without prior attempts at alternatives. Observations confirmed the use of side rails, and interviews with staff revealed a lack of awareness about the requirement to try alternatives first.
A nurse in an LTC facility verbally and physically abused a severely cognitively impaired resident. The nurse yelled at the resident, slapped his arm, and threw a shoe at him while he was on the floor, possibly in a postictal state. Witnesses reported the incident, leading to the nurse's removal and an investigation that substantiated the abuse.
A resident with diabetes and hemiplegia was not provided with necessary nail care despite being dependent on staff for personal hygiene. The resident's long fingernails were observed over several days, and although he requested assistance, it was not provided. The DON and nursing staff acknowledged the oversight, as the resident's care plan required staff assistance for grooming.
Recurring Sewage Backups Due to Corroded Pipes
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment due to recurring issues with corroded sewage pipes that caused sewage to back up onto the hallway floors. Observations and interviews revealed that the sewage backup occurred in two of the four hallways reviewed, specifically the 200 and 500 halls. The sewage overflowed from cleanout access points in the hallways, leading to toilets overflowing in resident rooms. This issue was reported to have been ongoing for several years, with backups occurring at least once a month, and more frequently during heavy rainfalls. Interviews with residents and staff indicated that the sewage backups were a regular occurrence, causing inconvenience and potential hazards. Residents reported that when the sewage overflowed, they were unable to use their toilets and had to rely on alternative facilities or bedside commodes. Staff members, including housekeepers and nursing assistants, described the process of cleaning up the sewage, which involved mopping up the water, placing wet floor signs, and using towels and blankets to contain the overflow. The maintenance director and plumbers confirmed that the sewage lines were old and corroded, contributing to the frequent clogs and backups. The facility's administration and property management were aware of the issue, with the corporate VP of Property Management acknowledging the need for pipe replacement to permanently resolve the problem. Despite recommendations from the plumbing company to replace the corroded pipes, only partial replacements had been made due to the high cost. The ongoing sewage backups were attributed to the deteriorated condition of the pipes, with corrosion and debris causing blockages. The facility's medical director expressed concern about potential infection control issues if residents came into direct contact with the sewage.
Recurring Sewage Backup Creates Safety Hazard
Penalty
Summary
The facility failed to maintain and repair corroded sewage pipes, resulting in sewage backup in two of the four hallways reviewed for accident hazards. Observations and interviews revealed that the sewage backup occurred in the 200 and 500 hallways, causing water to pool on the floors and creating a slip hazard. Housekeeper #1 was observed mopping up water in the 200 hallway, where grayish liquid was seeping from a sewer cleanout port. The issue was recurrent, with staff and residents reporting that the sewage backup happened multiple times a month, particularly during heavy rain. Interviews with staff and residents highlighted the ongoing nature of the problem. Housekeeper #1 and Nurse Aide #5 described how the sewage backup led to toilets overflowing and water pooling in resident rooms, creating a safety hazard. Resident #11, who was alert and oriented, reported that the flooding occurred at least three times a month, making it difficult for her to move around her room due to the risk of falling. Staff members, including Nurse #6 and the Assistant Director of Nursing, confirmed that the issue had been persistent for years, with wet floor signs and towels used to mitigate the slip hazard until maintenance could address the clogs. The facility's Administrator acknowledged the problem, noting that while wet floors posed a fall risk, no falls had been reported as a result of the sewage overflow. Despite the measures taken to manage the immediate hazard, the recurring nature of the sewage backup indicates a failure to adequately address the underlying plumbing issues, leading to repeated safety hazards for residents and staff.
Failure to Replace Corroded Sewer Lines Leads to Frequent Sewage Backups
Penalty
Summary
The governing body of the facility failed to ensure the replacement of aged, malfunctioning, and corroded sewer lines, leading to frequent sewage backups. The Maintenance Director reported that the sewer lines on the 200 and 500 halls were particularly problematic, with backups occurring multiple times each month. These backups resulted in toilets overflowing and sewage spilling into the hallways. The Maintenance Director had been dealing with this issue for seven years, often having to use an auger to attempt to clear the clogs, and frequently calling a plumber when these efforts were unsuccessful. Interviews with the facility's plumbers revealed that the sewer lines were made of old cast iron pipes that had corroded, causing holes and allowing sewage to drain into the soil beneath the facility. Plumber #1 and Plumber #2 both confirmed that the corrosion and erosion of the pipes were severe, and they had recommended replacing the sewer lines to the facility's corporate President of Property Management. Despite these recommendations, only portions of the most severely damaged pipes had been replaced, leaving the remaining lines in a deteriorated condition. The corporate President of Property Management acknowledged the ongoing issue and the need for extensive pipe replacement but cited the high cost as a barrier to completing the necessary repairs. The Administrator, who had been with the facility for six months, was aware of the sewage backup issues but believed they were caused by residents flushing inappropriate items. The facility was unable to provide a current quote for the recommended repairs, indicating a lack of immediate plans to address the underlying problem.
Failure to Develop Comprehensive Care Plan for Resident with G-Tube
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with osteomyelitis of the vertebra and sacral region and had a gastrostomy tube (g-tube) for nutrition, hydration, and medication. A review of the resident's care plan dated March 19, 2025, revealed that it did not address the resident's g-tube. During an interview, the MDS Nurse acknowledged that she should have included a care plan for the g-tube but did not provide a reason for its omission. The Director of Nursing was unaware of the missing care plan, and the Administrator confirmed that the resident should have had a care plan for the g-tube.
Lack of Physician's Order for G-Tube Care
Penalty
Summary
The facility failed to ensure there was a physician's order for the care of a gastrostomy tube (g-tube) site for a resident who was admitted with a g-tube. The resident, who was severely cognitively impaired, did not have a care plan addressing the g-tube, and there was no physician's order for skin care and dressing changes at the g-tube insertion site. Despite this, the resident's Medication Administration Record indicated that a nutritional supplement was administered via the g-tube regularly. During an observation and interview, a nurse revealed that she sometimes cleaned the g-tube site and applied a dressing based on her past experience, without a specific order. The Wound Care Nurse, who was responsible for the g-tube site care, also admitted to providing care without a written order, believing it was unnecessary. The Director of Nursing and the Administrator confirmed that care for the g-tube site should have been conducted with a physician's order, highlighting a lapse in following professional standards of quality care.
Deficiencies in Enteral Feeding and G-Tube Management
Penalty
Summary
The facility failed to properly manage enteral feeding for Resident #28, who was admitted with hemiplegia and hemiparesis following a stroke and required a gastrostomy tube for nutrition. Observations revealed that the enteral formula bag, water flush bag, and syringe were not labeled with the date and time they were hung, and the syringe was improperly stored with the piston inside the barrel, which could lead to bacterial growth. Nurse #4 admitted to not labeling the bags due to time constraints and storing the syringe incorrectly, citing a lack of training on enteral feeding. Additionally, the enteral feeding machine was set to administer the feed at 55 cc per hour instead of the physician-ordered 60 cc per hour, as the Assistant Director of Nursing (ADON) set the machine based on memory without verifying the order. For Resident #58, who was admitted with osteomyelitis and a gastrostomy tube, the facility failed to ensure there was a physician's order for free water flushes. The resident's care plan did not address the g-tube, and the physician's orders did not include free water flushes. Nurse #4 administered 150 mls of free water flushes after giving a liquid dietary supplement, based on past practices with other residents, without a physician's order. The Director of Nursing (DON) confirmed that Nurse #4 should not have administered the flushes without an order and should have consulted the physician. The deficiencies highlight a lack of proper labeling, storage, and adherence to physician orders in the management of enteral feeding and g-tube care. The facility's staff, including Nurse #4 and the ADON, did not follow established protocols, leading to potential risks for the residents involved. The DON and Administrator acknowledged the lapses in procedure and the need for proper training and adherence to physician orders.
Infection Control Breach During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to professional standards of practice and infection prevention measures during tracheostomy care for a resident. The incident involved a nurse who did not perform hand hygiene or don sterile gloves after handling soiled items, such as a split gauze pad and inner cannula, before placing new sterile items. This lapse in procedure was observed during tracheostomy care for a resident with significant cognitive impairment and a history of hemiplegia and hemiparesis following a stroke. The resident was documented to receive tracheostomy care in the facility. During the procedure, the nurse initially performed hand hygiene and donned sterile gloves but failed to maintain sterility after handling contaminated items. The nurse admitted to not following proper protocol, which was confirmed by the Infection Preventionist and the Medical Director. Both emphasized the importance of maintaining sterility to prevent bacterial introduction to the resident's respiratory system. The facility administrator also acknowledged the breach in protocol, noting the potential for bacteria transfer from soiled gloves to sterile items.
Failure to Monitor and Document Dialysis Care
Penalty
Summary
The facility failed to maintain proper documentation and monitoring for a resident requiring dialysis care. The resident, who was admitted with End Stage Renal Disease and required hemodialysis, had no documented weights recorded in their medical record since November 2024. The resident's care plan included monitoring for weight loss due to potential fluid deficit related to fluid restriction and hemodialysis. However, the facility was unable to locate the dialysis communication forms, which were essential for tracking the resident's weight and ensuring proper care. The Unit Manager and Assistant Director of Nursing were unaware of the missing documentation and weight discrepancies, indicating a lapse in communication and record-keeping. Interviews with facility staff, including the Registered Dietitian and Medical Director, revealed that the resident had stopped attending dialysis for several months, leading to hospitalization for fluid overload. Despite resuming dialysis in January 2025, the facility did not update the resident's weight records, relying instead on outdated information. The Director of Nursing and Administrator were also unaware of the lack of recorded weights, highlighting a systemic issue in monitoring and documenting the resident's condition. The Medical Director acknowledged the expected weight loss due to fluid retention but emphasized the facility's responsibility to monitor weights independently of dialysis records.
Failure to Attempt Alternatives Before Installing Side Rails
Penalty
Summary
The facility failed to attempt alternatives before installing side rails for three residents. Resident #1, who was admitted with hemiplegia and hemiparesis, had a care plan that included the use of a side rail for bed mobility. However, the side rail assessment form completed by the MDS Nurse did not include any questions about attempting alternatives before implementing side rails. Observations confirmed the side rail was in use, and interviews with the MDS Nurse, ADON, and DON revealed a lack of awareness about the requirement to try alternatives first. Resident #9, admitted with end-stage renal disease, also had side rails installed without attempting alternatives. The side rail assessment form completed by the ADON similarly lacked questions about alternatives. Observations showed the side rails in use, and interviews with the ADON and DON confirmed they were unaware of the requirement to try alternatives before using side rails. Resident #58, admitted with osteomyelitis, had side rails in use without any reference to them in the care plan. The side rail assessment form completed by the ADON did not address alternatives, and observations confirmed the side rail was in use. Interviews with the ADON, DON, and Administrator revealed a lack of awareness and documentation regarding the requirement to attempt and document alternatives before implementing side rails.
Resident Abuse by Nurse in LTC Facility
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident's right to be free from verbal and physical abuse. The incident involved a nurse who entered the resident's room, found him lying on the floor, and yelled at him to get up. When the resident reached out to the nurse for assistance, she slapped him on his upper left arm and used derogatory language. This incident was witnessed by other staff members who reported the nurse's behavior. The resident involved was admitted to the facility with diagnoses including dementia, blindness, and epilepsy. He was assessed as severely cognitively impaired and required assistance for toilet transfers. On the day of the incident, the resident was found on the floor, and it was suspected that he might have been in the postictal phase of a seizure, which could explain his lack of memory of the event. Despite this, the nurse's actions were deemed abusive by the facility's investigation. Witness statements from other staff members corroborated the account of the nurse's abusive behavior. They reported that the nurse yelled obscenities at the resident, slapped his arm, and threw a shoe at him. The nurse was described as becoming increasingly frustrated and emotional during the incident. The facility's administration was notified, and the nurse was removed from the premises pending an investigation, which ultimately substantiated the abuse allegations.
Failure to Provide Nail Care to Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a dependent resident, identified as Resident #3, who was admitted with diagnoses including diabetes mellitus and hemiplegia affecting his right side. Resident #3 was assessed as cognitively intact and dependent on staff for personal hygiene. Despite being care planned for assistance with activities of daily living, including personal hygiene and grooming, Resident #3's fingernails were observed to be excessively long over several days. He had requested nail care from a staff member, but it was not provided, and he was unable to clip his own nails due to his condition. The Director of Nursing acknowledged that Resident #3's nails were too long and should have been clipped, especially given his diabetic status, which requires nursing staff to perform nail care. Nurse #5, responsible for Resident #3's care, stated she was unaware of the need for nail care as no one had informed her, and she had not observed the length of his nails. Similarly, Nurse Aide #4, who provided care to Resident #3, did not notice the long nails and was not informed by the resident. This oversight resulted in a failure to meet the resident's personal hygiene needs as outlined in his care plan.
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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 Plymouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Three Rivers Health And Rehabilitation Center | 13.6 mi | ★★★★★ | 3 | 0 |
| Windsor Rehabilitation And Healthcare Center | 13.7 mi | ★★★★★ | 15 | 0 |
| Chowan River Nursing And Rehabilitation Center | 17.2 mi | ★★★★★ | 0 | 0 |
| The Carrolton Of Williamston | 22.5 mi | ★★★★★ | 4 | 0 |
| Ridgewood Living & Rehabilitation Center | 26.2 mi | ★★★★★ | 11 | 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.