The Carrolton of Dunn

Inspectors wroteBased on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 2 of 30 days reviewed for staffing (8/30/25 and 8/31/25).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Form 10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notification (ABN) when the facility-initiated discharge from Medicare Part A Services when benefit days were not exhausted. This was for 2 of 3 residents reviewed for beneficiary notice protection (Resident #8 and Resident #68).

Inspectors wroteBased on observations and staff interviews the facility failed to label and date leftover food items and failed to discard food with signs of spoilage in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer. The facility also failed to ensure clean dishes were not stacked wet and ensure dishes that were ready for use were clean for 1 of 2 kitchen observations. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to honor residents the choice to warm meals brought from outside the facility for 3 of 3 residents reviewed for choices (Resident #8, Resident #25 and Resident #5).

Inspectors wroteBased on record review and staff interviews, the facility failed to implement their abuse policy and procedure for immediately reporting an allegation of staff to resident physical abuse to the Administrator resulting in the allegation not being reported to the State Agency, local law enforcement, and to Adult Protective Services within the required time frame. Additionally, the initial report did not accurately reflect the date and time the facility became aware of the abuse allegation. This was for 1 of 3 residents reviewed for abuse (Resident #37).

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to treat residents in a dignified manner by failing to knock on doors or ask permission to enter resident rooms for 3 of 8 residents (Resident #2, Resident #10 and Resident #13) reviewed for dignity. The reasonable person concept was applied to this deficiency as individuals have the expectation of a person knocking and identifying themself before entering their room.

Inspectors wroteBased on record review, and interviews with staff, therapy staff, and the Physician the facility failed to notify the physician when Resident # 3 experienced a change in status resulting in a decline observed by multiple staff members. Resident # 3 entered the facility for rehabilitation. Therapists and Nurse Aides revealed Resident # 3 was initially making progress in therapy to the degree that she could feed herself, ambulate short distances with therapy in parallel bars or with a quad cane, toilet to the commode, and communicate her needs by gestures. [...]

Inspectors wroteBased on record review and interviews with staff, responsible party (RP), therapy staff, and the Physician, the facility failed to obtain labs as directed by the physician and ensure staff effectively communicated amongst themselves in order that a change in condition be recognized by the licensed nursing staff and a resident receive evaluation and necessary medical treatment. Resident # 3 entered the facility for rehabilitation. Therapists and Nurse Aides revealed Resident # 3 was initially making progress in therapy to the degree that she could feed herself, ambulate short distances with therapy in parallel bars or with a quad cane, toilet to the commode, and communicate her needs by gestures. Days prior to a hospital discharge, Resident # 3 had a decline in functional status that included symptoms of dizziness, lightheadedness, nausea, and periods of altered responsiveness. [...]

Inspectors wroteBased on observations, record reviews, staff and physician interviews, the facility failed to notify the physician of tube feedings (nutrition administered through a tube directly into the stomach) that were ordered continuously being turned off for 2 of 2 residents (Resident #60 and Resident #74) for an undetermined amount of time and instances. During observations on 10/3/24 Resident #60's and Resident #74's feeding tube pumps (the mechanism that delivers the nutrition) were observed off. Nurse #1 confirmed she turned Resident #60's and Resident #74's tube feedings off without notifying the physician despite her knowledge that the tube feedings were ordered continuously because she believed their stomach needed a rest. Nurse #1 also confirmed this was not an isolated incident for either resident and she had done this before without notifying the physician. [...]

Inspectors wroteBased on record review, observation, and staff and physician interviews, the facility failed to protect the residents' right to be free from neglect when Nurse #1 did not provide the necessary care and services as assessed and ordered by the physician to Resident #60 and Resident #74. On 10/03/24 Nurse #1 turned their continuous tube feedings (nutrition administered through a tube directly into the stomach) off because she believed their stomachs needed a rest. Nurse #1 was aware of the physician's orders, she deliberately disregarded them, and she independently made the decision to deviate from the physician's orders and turn the tube feedings off depriving the residents of their assessed nutritional needs. She revealed this was not a new practice for her and she had done this previously for both residents an undetermined number of times. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 8 of 21 residents' MDS assessments reviewed (Resident #s 5, 10, 13, 49, 62, 63, 69, and 71).

Inspectors wrote3. Resident #341 admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed), dysphagia (trouble swallowing), and had a gastrostomy tube (a g-tube, feeding tube into the stomach) and tracheostomy (breathing tube into the trachea). Resident #341's Minimum Data Set (MDS) dated [DATE] noted he was unable to participate in the assessment, had an altered level of consciousness, had a tracheostomy, and he had a g-tube and consumed more than 51% of his calories and more than 501 cubic centimeters (cc) of fluids through the g-tube. The MDS indicated he had an unhealed Stage IV wound (a wound down to the bone). Resident #341's physician orders dated 9/12/24 noted he was to receive tube feeding 1.5 calorie formula at 50 cc an hour and a water flush at a rate of 200 ml every 6 hours. [...]

Inspectors wroteBased on interviews with staff and record reviews, the facility failed to ensure a resident's code status election was accurate throughout the medical record for 1 of 2 residents reviewed for advanced directives (Resident #341).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete the admission Minimum Data Set (MDS) assessment within the required timeframe for 1 of 1 newly admitted resident reviewed for MDS assessments (Resident #341).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that a resident with diagnoses of mental disorders had received a Level 2 Preadmission Screening and Resident Review (PASRR) after admission to the facility for 1 of 2 residents reviewed for PASRR (Resident #26).

Inspectors wroteBased on record review and staff interviews, the facility failed to create a baseline care plan within 48 hours of a resident's admission for 1 of 2 residents (Resident #341) reviewed for baseline care plans.

Inspectors wroteBased on record review, observation, resident representative interview, and staff interviews, the facility failed to provide incontinence care to a resident that was dependent on staff for activities of daily living (ADL) for 1 of 1 resident reviewed (Resident #20).

Inspectors wroteBased on record review and staff interviews, the facility failed to conduct and document an admission screening assessment to identify and communicate any changes in the resident's cognitive and functional levels after an hospitalization for 1 of 1 resident reviewed for activities of daily living (Resident #20).

Inspectors wroteBased on record review and staff interviews, the facility failed to have a registered nurse daily for 8 consecutive hours, 7 days a week for 3 of 60 days reviewed (8/3/24, 8/18/24 and 9/15/24).

Inspectors wroteBased on record review, staff interviews and Consultant Pharmacist interview, the facility failed to address recommendations made by the Consultant Pharmacist for 1 of 5 residents reviewed for unnecessary medications (Resident #84).

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to discard an expired insulin aspart flex pen from 1 of 4 medication carts observed for medication storage (300-hall medication cart).

Inspectors wroteBased on observations, staff and resident interviews, and record reviews, the facility failed to maintain an effective pest control program to prevent mice from entering the facility for 2 of 4 halls (200 and 300 halls).

Inspectors wroteBased on record review and staff interviews, the facility failed to report allegations of abuse and neglect to Adult Protective Services (APS). This deficient practice was for 3 of 4 residents reviewed for abuse. (Resident #1, Resident #4, and Resident #6).

Inspectors wroteBased on observations, record review, resident interviews and staff interviews, the facility failed to honor residents' choice related to showers for 4 of 5 dependent residents reviewed for choices (Resident #45, Resident #42, Resident #14, and Resident #33).

Inspectors wrote2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder. A progress note dated 2/22/23 revealed a gradual dosage reduction of an antipsychotic medication was contraindicated. Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a gradual dosage reduction of an antipsychotic medication was not contraindicated. During an interview with MDS Nurse #2 on 6/1/23 at 1:22 PM she stated Resident #55's assessment should have been coded to reflect a contraindication of gradual dose reduction for an antipsychotic medication. She reported there was some confusion about this and thought the contraindication had to be done during the 7-day lookback period. An interview was conducted with the Administrator on 6/2/23 at 2:24 PM. [...]

Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to: 1) conduct quarterly care plan meetings with cognitive residents and/or the resident representatives (Resident #45, Resident #42, and Resident #77) and 2) revise a resident's care plan post a fall with new fall prevention interventions (Resident #77) for 3 of 13 residents reviewed for care planning.

Inspectors wroteBased on observations, record reviews, resident interviews and staff interviews, the facility failed to provide sufficient nurse staff to ensure 4 of 4 dependent residents received scheduled showers (Resident #45, Resident #42, Resident #14, and Resident #33).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to attach an indwelling urinary catheter tubing to a secure device to prevent tension and possible injury for 1 of 1 resident reviewed for urinary catheter (Resident #61).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to follow orders for the use of oxygen for 1 of 3 residents reviewed for oxygen use (Resident #74).

Inspectors wroteBased on record review, resident, resident representative and staff interviews, the facility failed to explain the arbitration agreement to the resident or resident representative prior to having them sign the agreement and to ensure they explicitly informed the resident/representative that signing the agreement was not required as a condition of admission. This occurred for 2 of 3 residents (Resident #9 and Resident #45) reviewed for arbitration.

Inspectors wroteBased on record review and staff interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the complaint survey of 11/9/22. The deficiency is in the area of respiratory care (F695). The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on observations, resident interviews and staff interviews, the facility failed to inform residents (Resident #47, #42, #45, #59 and #41) the location of the state inspection results and failed to display state inspection results accessible to a wheelchair bound resident (Resident #45) for 6 of 6 residents in attendance of the Resident Council meeting.

Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to resolve and provide a written grievance response for 2 of 2 residents reviewed for grievances (Resident #45, Resident #42).

Inspectors wroteBased on record review and staff interviews the facility failed to provide written notice of the reason for transfer to the resident and/or responsible party (RP) for 1 of 1 resident (Resident #86) reviewed for hospitalization.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the bed hold policy in writing at the time of transfer to 1 of 1 resident discharged to the hospital (Resident #86). This practice had the potential to impact other residents.

Inspectors wroteBased on record review and staff interviews the facility failed to transmit and/or complete discharge Minimum Data Set (MDS) assessments within the required timeframe for 2 of 2 residents reviewed for discharge. (Resident #38 and Resident #78).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement an individualized care person centered care plan in the areas of Activity of Daily Living (ADL) and discharge for 2 of 21 residents reviewed for comprehensive care plans (Resident #45, Resident #88).