Fayetteville, NC

The Carrolton of Fayetteville

2-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

2461 Legion Road, Fayetteville, NC

(910) 424-9417

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

117

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Carrolton Nursing Homes

Operator or chain grouping

Approved since

1991-06-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.23

Registered nurse staffing

LPN hours / resident day

0.68

Licensed practical nurse staffing

Aide hours / resident day

2.21

Nurse aide staffing

Weekend hours

2.84

Weekend nurse staffing

RN turnover

67%

Annual RN turnover

Total nurse turnover

52%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	1.8 About the same	1.9 0.1 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	1.8 0.9 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	47.4%	91.5% 44.1 pts worse	93.4% 46 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	45.5%	94.1% 48.6 pts worse	95.5% 50 pts worse	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	5.2%	3.6% 1.6 pts worse	3.3% 1.9 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	3.7%	4.8% 1.1 pts better	11.4% 7.7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	10.7%	7.2% 3.5 pts worse	5.4% 5.3 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.5%	21.6% 4.1 pts better	19.6% 2.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	16.5%	15.0% 1.5 pts worse	16.7% 0.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	10.9%	21.5% 10.6 pts better	16.3% 5.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	7.9%	16.8% 8.9 pts better	14.9% 7 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.9% 0.2 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	2.4%	2.6% 0.2 pts better	1.7% 0.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.4%	21.2% 4.2 pts worse	19.8% 5.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	7.2%	6.0% 1.2 pts worse	5.1% 2.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	11.2%	79.9% 68.7 pts worse	81.7% 70.5 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	10.7%	13.2% 2.5 pts better	12.0% 1.3 pts better	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	2.3%	1.5% 0.8 pts worse	1.6% 0.7 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	8.4%	78.1% 69.7 pts worse	79.7% 71.3 pts worse	Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.3%	22.9% 1.4 pts worse	23.9% 0.4 pts worse	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-12 · Fire 2024-06-14

4 health deficiencies

Top issue: Resident Rights (2 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2024-06-14 · Fire 2018-07-03

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2018-07-03 · Fire 2017-07-21

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-06-14

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-30

F · Potential for more than minimal harm 2024-06-14

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2024-08-30

F · Potential for more than minimal harm 2024-06-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-06-14

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-08-30

D · Potential for more than minimal harm 2024-06-14

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-08-30

F · Potential for more than minimal harm 2018-07-03

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2018-07-27

F · Potential for more than minimal harm 2018-07-03

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2018-07-27

E · Potential for more than minimal harm 2018-07-03

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2018-07-27

F · Potential for more than minimal harm 2017-07-21

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2017-09-20

F · Potential for more than minimal harm 2017-07-21

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2017-09-20

F · Potential for more than minimal harm 2017-07-21

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2017-09-20

E · Potential for more than minimal harm 2017-07-21

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2017-09-20

E · Potential for more than minimal harm 2017-07-21

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2017-09-20

E · Potential for more than minimal harm 2017-07-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2017-09-20

E · Potential for more than minimal harm 2017-07-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2017-09-20

D · Potential for more than minimal harm 2017-07-21

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2017-09-20

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-12

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-10-03

D · Potential for more than minimal harm 2025-09-12

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-10-03

D · Potential for more than minimal harm 2025-09-12

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2025-10-03

D · Potential for more than minimal harm 2025-09-12

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-10-03

D · Potential for more than minimal harm 2024-06-14

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-07-10

B · Minimal harm 2024-06-14

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-07-10

D · Potential for more than minimal harm 2024-06-04

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-05-30

D · Potential for more than minimal harm 2024-04-25

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-05-14

D · Potential for more than minimal harm 2024-04-02

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-04-02

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-04-01

E · Potential for more than minimal harm 2024-02-29

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-02-29

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-02-29

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-04-01

D · Potential for more than minimal harm 2024-02-29

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-04-01

J · Immediate jeopardy 2018-07-03

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2018-07-11

J · Immediate jeopardy 2018-07-03

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2018-07-11

G · Actual harm 2018-07-03

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2018-07-11

F · Potential for more than minimal harm 2018-07-03

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2018-07-11

F · Potential for more than minimal harm 2018-07-03

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2018-07-11

F · Potential for more than minimal harm 2018-07-03