11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Plymouth, NC
2-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1084 US 64 East, Plymouth, NC
(252) 793-2100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
114
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carrolton Nursing Homes
Operator or chain grouping
Approved since
1987-11-11
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
RN hours / resident day
0.33
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.01
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.68
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.22
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
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
3,964
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9948
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.02
Baseline 7.45% · Performance 7.23% · Measure score 2.02 · Achievement 2.02 · Improvement 0.39
Total nurse turnover
9.12
Baseline 29.31% · Performance 26.41% · Measure score 9.12 · Achievement 9.12 · Improvement 5.99
Adjusted total nurse staffing
1.44
Baseline 3.70 hours · Performance 3.49 hours · Measure score 1.44 · Achievement 1.44 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.2% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 19.51% · Lower 95% interval 6.88% |
| Discharge to community | 48.71% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 42.11% · Lower 95% interval 34.76% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 4% |
0.77%
3.2 pts worse
|
Numerator 1 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 20% |
2.29%
17.7 pts worse
|
Numerator 5 · Denominator 25 · Adjusted rate 13.96% |
| Healthcare-associated infections requiring hospitalization | 7.23% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 3.64% |
| Staff COVID-19 vaccination coverage | 1.35% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 74 |
| Staff flu vaccination coverage | 12.66% |
42%
29.3 pts worse
|
Numerator 10 · Denominator 79 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.8
1.3 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.5%
6.7 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.9% · Q4 97.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.1%
2.1 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.6%
3.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.8%
4.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
7.2%
2.3 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.0% · Q3 2.9% · Q4 4.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.9% |
21.6%
13.3 pts worse
|
19.6%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 32.4% · Q3 39.4% · Q4 40.9% · 4Q avg 34.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
15.0%
0.5 pts worse
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 13.0% · Q3 20.0% · Q4 14.3% · 4Q avg 15.5% · 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 | 11.1% |
21.5%
10.4 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 18.9% · Q3 18.2% · Q4 4.6% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.8%
7.5 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.7% · Q3 12.5% · Q4 11.5% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.6%
About the same
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 4.2% · Q4 1.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
21.2%
7.5 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 17.5% · Q3 20.7% · Q4 15.3% · 4Q avg 13.7% |
| Percentage of long-stay residents with pressure ulcers | 12.4% |
6.0%
6.4 pts worse
|
5.1%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 14.2% · Q3 14.3% · Q4 11.7% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.6% |
79.9%
24.3 pts worse
|
81.7%
26.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.4% · Q2 69.6% · Q3 54.1% · Q4 36.4% · 4Q avg 55.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
13.2%
5.6 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.6% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.2% |
1.5%
6.7 pts worse
|
1.6%
6.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 5.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.6% |
78.1%
13.5 pts worse
|
79.7%
15.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
22.9%
0.2 pts worse
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 22.9% · Expected 23.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-06
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-03
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-03
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-03
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-03
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-03
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-05-03
Inspection history
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-17
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2025-04-18
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-24
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-17
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-17
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-17
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-17
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-17
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-04-17
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-29
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-29
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-29
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-04-20
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-29
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-03-29
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-29
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-15
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-03-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-15
Health
Provide or obtain dental services for each resident.
Corrected 2023-03-15
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-03-15
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-03-15
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-10
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-15
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 2023-03-15
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-03-15
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 2023-03-15
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-15
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-15
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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