Cycle 1
Health 2024-11-21 · Fire 2024-11-21
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lumberton, NC
The Carrolton of Lumberton
1-star overall rating with 2-star inspections with $37,087 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1170 Linkhaw Road, Lumberton, NC
(910) 671-1163
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carrolton Nursing Homes
Operator or chain grouping
Approved since
1990-04-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.62
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.91
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,419
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.74% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.81
Performance 6.10% · Measure score 5.81 · Achievement 5.81 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.39
Performance 45.75% · Measure score 4.39 · Achievement 4.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.97
Performance 3.92 hours · Measure score 2.97 · Achievement 2.97 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 8.47% · Lower 95% interval 6.77% |
| Discharge to community | 44.02% |
50.57%
6.5 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 31.34% · Lower 95% interval 30.77% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 97.87% |
95.27%
2.6 pts better
|
Numerator 46 · Denominator 47 |
| Falls with major injury | 8.51% |
0.77%
7.7 pts worse
|
Numerator 4 · Denominator 47 |
| Discharge self-care score | 29.63% |
53.69%
24.1 pts worse
|
Numerator 8 · Denominator 27 |
| Discharge mobility score | 18.52% |
50.94%
32.4 pts worse
|
Numerator 5 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 47 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 3.92% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 2.08% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 96 |
| Staff flu vaccination coverage | 34.03% |
42%
8 pts worse
|
Numerator 49 · Denominator 144 |
| Discharge function score | 29.63% |
56.45%
26.8 pts worse
|
Numerator 8 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.8
1.7 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.5 |
1.8
2.7 pts worse
|
1.8
2.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.5 · Observed 5.3 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
91.5%
4.6 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 93.5% · Q4 91.1% · 4Q avg 96.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
94.1%
3.4 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.6%
1.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.0% · Q3 3.9% · Q4 6.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
4.8%
3 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 9.2% |
7.2%
2 pts worse
|
5.4%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 11.3% · Q3 8.7% · Q4 6.1% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.3% |
21.6%
6.7 pts worse
|
19.6%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 25.0% · Q3 30.4% · Q4 31.3% · 4Q avg 28.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
15.0%
7 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 23.5% · Q3 21.1% · Q4 20.0% · 4Q avg 22.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.3% |
21.5%
5.8 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 36.8% · Q3 19.6% · Q4 32.7% · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
16.8%
1.9 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 18.3% · Q3 20.6% · Q4 9.7% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.1% |
0.9%
3.2 pts worse
|
1.0%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 4.8% · Q3 2.3% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.6%
1.7 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 1.4% · Q3 3.9% · Q4 5.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.2% |
21.2%
12 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 11.0% · Q3 11.4% · Q4 8.5% · 4Q avg 9.2% |
| Percentage of long-stay residents with pressure ulcers | 12.3% |
6.0%
6.3 pts worse
|
5.1%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.6% · Q3 13.1% · Q4 12.1% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.7% |
79.9%
22.2 pts worse
|
81.7%
24 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 57.9% · Q3 50.9% · Q4 48.3% · 4Q avg 57.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
13.2%
2.2 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 18.5% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.1% · Q3 0.0% · Q4 3.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.6% |
78.1%
18.5 pts worse
|
79.7%
20.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
22.9%
6.4 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 18.5% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-25 · Fire 2023-05-25
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-01-25 · Fire 2018-01-25
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-16
F · Potential for more than minimal harm
2023-05-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-05-25
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 2023-07-29
D · Potential for more than minimal harm
2023-05-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-05-25
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-05-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-29
F · Potential for more than minimal harm
2018-01-25
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-03-19
E · Potential for more than minimal harm
2018-01-25
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 2018-03-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-11-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
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 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
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 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-19
E · Potential for more than minimal harm
2023-05-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-17
E · Potential for more than minimal harm
2023-05-25
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-25
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 2023-05-26
D · Potential for more than minimal harm
2023-05-25
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 2023-05-27
D · Potential for more than minimal harm
2023-05-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-05-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-04
D · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-04
B · Minimal harm
2023-05-25
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-26
K · Immediate jeopardy
2023-04-06
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 2023-05-25
K · Immediate jeopardy
2023-04-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-25
F · Potential for more than minimal harm
2018-01-25
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 2018-02-26
D · Potential for more than minimal harm
2018-01-25
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 2018-02-26
D · Potential for more than minimal harm
2018-01-25
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 2018-02-26
D · Potential for more than minimal harm
2018-01-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-02-26
D · Potential for more than minimal harm
2018-01-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-02-26
Penalties and ownership
What sits behind the stars
$37,087
2023-04-06
Fine
Fine · fine $37,087
Fine
$0
2023-04-06
Payment Denial
Payment Denial · denial start 2023-05-04 · 51 days
51 day denial
Ownership
C. Saunders Roberson, Jr., As Trustee Of The Judith Roberson Dixon Irr
5% Or Greater Direct Ownership Interest · Organization
Figlewski, Deborah
5% Or Greater Direct Ownership Interest · Individual
Powell, Earl
5% Or Greater Direct Ownership Interest · Individual
Powell, John
5% Or Greater Direct Ownership Interest · Individual
Russell, Denise
5% Or Greater Direct Ownership Interest · Individual
Carrolton Facility Management, LLC
Operational/Managerial Control · Organization
Roberson, Carrol
Operational/Managerial Control · Individual
Rozier, Sonya
Operational/Managerial Control · Individual
Nearby options
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3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Woodhaven Nursing Center
Lumberton, NC
1-star overall rating with 1-star inspections with $128,210 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Harborview Lumberton
Lumberton, NC
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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