Cycle 1
Health 2025-07-03 · Fire 2024-03-13
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Williamston, NC
The Carrolton of Williamston
2-star overall rating with 2-star inspections with $45,102 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
119 Gatling Street, Williamston, NC
(252) 792-1616
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
Facility snapshot
Beds
154
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carrolton Nursing Homes
Operator or chain grouping
Approved since
1980-11-01
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
0.36
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.76
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
0.86
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,638
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.53
Baseline 62.92% · Performance 41.10% · Measure score 5.53 · Achievement 5.53 · Improvement 5.23
Adjusted total nurse staffing
0.91
Baseline 3.62 hours · Performance 3.34 hours · Measure score 0.91 · Achievement 0.91 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.39% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 20.97% · Lower 95% interval 8.51% |
| Discharge to community | 38.38% |
50.57%
12.2 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 28.26% · Lower 95% interval 28.07% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 63.33% |
95.27%
31.9 pts worse
|
Numerator 19 · Denominator 30 |
| Falls with major injury | 3.33% |
0.77%
2.6 pts worse
|
Numerator 1 · Denominator 30 |
| Discharge self-care score | 29.63% |
53.69%
24.1 pts worse
|
Numerator 8 · Denominator 27 |
| Discharge mobility score | 37.04% |
50.94%
13.9 pts worse
|
Numerator 10 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 10% |
2.29%
7.7 pts worse
|
Numerator 3 · Denominator 30 · Adjusted rate 8.55% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 79 |
| Staff flu vaccination coverage | 1.08% |
42%
40.9 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge function score | 37.04% |
56.45%
19.4 pts worse
|
Numerator 10 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 64.8% |
91.5%
26.7 pts worse
|
93.4%
28.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.1% · Q2 65.7% · Q3 64.2% · Q4 59.4% · 4Q avg 64.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.0% |
94.1%
2.1 pts worse
|
95.5%
3.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.6%
1.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.5% · Q3 5.5% · Q4 2.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.8%
4.3 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 13.1% |
7.2%
5.9 pts worse
|
5.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 18.3% · Q3 11.5% · Q4 11.3% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.7% |
21.6%
13.1 pts worse
|
19.6%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 33.3% · Q3 34.3% · Q4 36.6% · 4Q avg 34.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.2% |
15.0%
9.2 pts worse
|
16.7%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 26.2% · Q3 26.2% · Q4 22.5% · 4Q avg 24.2% · 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 | 14.8% |
21.5%
6.7 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 12.6% · Q3 17.9% · Q4 10.5% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
16.8%
3.9 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 8.2% · Q3 19.0% · Q4 13.8% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 1.4% · Q4 0.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.6%
2.1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.2% |
21.2%
11 pts better
|
19.8%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 11.1% · Q3 6.7% · Q4 11.8% · 4Q avg 10.2% |
| Percentage of long-stay residents with pressure ulcers | 13.7% |
6.0%
7.7 pts worse
|
5.1%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 15.0% · Q3 16.1% · Q4 10.8% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 17.9% |
79.9%
62 pts worse
|
81.7%
63.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 15.6% · Q3 20.5% · Q4 23.8% · 4Q avg 17.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.8% |
13.2%
9.6 pts worse
|
12.0%
10.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 23.1% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 23.9% |
78.1%
54.2 pts worse
|
79.7%
55.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 23.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.4% |
22.9%
9.5 pts better
|
23.9%
10.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 11.5% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-13 · Fire 2022-11-18
22 health deficiencies
Top issue: Nursing and Physician Services (6 deficiencies)
8 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Cycle 3
Health 2022-11-18 · Fire 2021-06-10
19 health deficiencies
Top issue: Resident Rights (9 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-03
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-07-19
E · Potential for more than minimal harm
2024-03-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-03-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-03-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-03-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-03-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-03-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-24
F · Potential for more than minimal harm
2022-11-18
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-11-18
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-11-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-11-18
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 2023-02-17
D · Potential for more than minimal harm
2022-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-11-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-17
D · Potential for more than minimal harm
2022-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-17
E · Potential for more than minimal harm
2021-06-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-07-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-27
D · Potential for more than minimal harm
2026-01-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2026-01-27
D · Potential for more than minimal harm
2025-07-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-19
D · Potential for more than minimal harm
2025-07-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-07-19
D · Potential for more than minimal harm
2025-07-03
F584 · Resident Rights Deficiencies
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 2025-07-19
D · Potential for more than minimal harm
2025-07-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-19
D · Potential for more than minimal harm
2025-07-03
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 2025-07-19
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-24
D · Potential for more than minimal harm
2024-11-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-24
G · Actual harm
2024-03-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-12
G · Actual harm
2024-03-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-13
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 2024-04-12
F · Potential for more than minimal harm
2024-03-13
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F584 · Resident Rights Deficiencies
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 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-03-13
F947 · Nursing and Physician Services Deficiencies
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 2024-04-12
D · Potential for more than minimal harm
2024-03-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-13
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 2024-04-12
D · Potential for more than minimal harm
2024-03-13
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 2024-04-12
D · Potential for more than minimal harm
2024-03-13
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 2024-04-12
C · Minimal harm
2024-03-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-12
B · Minimal harm
2024-03-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-04-12
B · Minimal harm
2023-09-07
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 2023-10-06
F · Potential for more than minimal harm
2022-11-18
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2022-12-21
E · Potential for more than minimal harm
2022-11-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-18
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-12-21
E · Potential for more than minimal harm
2022-11-18
F584 · Resident Rights Deficiencies
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 2022-12-30
E · Potential for more than minimal harm
2022-11-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-19
E · Potential for more than minimal harm
2022-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-30
E · Potential for more than minimal harm
2022-11-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-23
D · Potential for more than minimal harm
2022-11-18
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-21
D · Potential for more than minimal harm
2022-11-18
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 2022-12-30
D · Potential for more than minimal harm
2022-11-18
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 2022-12-16
D · Potential for more than minimal harm
2022-11-18
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 2022-12-20
D · Potential for more than minimal harm
2022-11-18
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 2022-12-12
D · Potential for more than minimal harm
2022-11-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-19
C · Minimal harm
2022-11-18
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-12-21
B · Minimal harm
2022-11-18
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-12-21
Penalties and ownership
What sits behind the stars
$45,102
2024-03-13
Fine
Fine · fine $45,102
Fine
Ownership
C. Saunders Roberson, Jr., As Trustee Of The Judith Roberson Dixon Irr
5% Or Greater Direct Ownership Interest · Organization
C. Saunders Roberson, Jr., Trustee Of The Carol Saunders Roberson Fami
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
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#3
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5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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