The Carrolton of Lumberton

Inspectors wroteBased on observations, record review, and interviews with resident, staff, Pharmacy Director and Nurse Practitioner, the facility failed to protect the residents' right to be free from misappropriation of narcotic pain medications (Tramadol, Hydrocodone-Acetaminophen, Oxycodone, and Oxycodone-Acetaminophen) for 9 of 9 residents reviewed for misappropriation of controlled medications (Residents #21, #2, #16, #34, #43, #52, #69, #79, and #87).

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to obtain orders to access and manage a port-a-cath (an implantable device placed under the skin, usually in the chest, to provide long-term, easy access to veins for chemotherapy, medications, blood draws, or intravenous fluids) for 1 of 1 sampled resident with a port-a-cath (Resident #1).

Inspectors wroteBased on record review and interviews with staff, Consultant Pharmacist, Pharmacy Nurse Consultant, and Pharmacy Director, the facility failed to have effective safeguards and systems in place for the accounting of controlled medications and the return of discontinued controlled medications to the pharmacy to prevent drug diversion for 9 of 9 residents reviewed for misappropriation of medications (Resident #69, #43, #2, #21, #16, #34, #52, #79, and #87).

Inspectors wroteBased on record review, and staff and Consultant Pharmacist's interviews, the facility failed to a.) act on the Consultant Pharmacist's recommendation to address a residents (Resident #12) diuretic medication Metolazone (used to treat high blood pressure and fluid retention caused by heart failure or kidney disease) that was prescribed for increased edema. The Consultant Pharmacist reported during the monthly medication regimen review in October 2025 and November 2025 that Resident #12 was receiving Metolazone outside of the physician ordered parameters which were to hold the medication if the residents systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. [...]

Inspectors wroteBased on observation, record review, and staff, resident, Nurse Practitioner and the Consultant Pharmacist interviews, the facility failed to hold the medication Metolazone (a diuretic medication used to treat high blood pressure and fluid retention caused by heart failure or kidney disease) when a resident's blood pressure was less than 110 systolic or less than 60 diastolic according to the parameters ordered by the physician. This resulted in a significant medication error as Resident #12 received 57 doses when the medication should have been held. Resident #12 experienced no significant outcome from receiving the medication. This occurred for 1 of 6 residents reviewed for medication administration (Resident #12).

Inspectors wroteBased on record review, observations, and Registered Dietician (RD) and staff interviews, the facility failed to honor residents' choices to have food items stored in the refrigerator and reheated for later consumption for 3 of 9 residents reviewed for self-determination (Resident #28, Resident #48, Resident #71).

Inspectors wroteBased on record review and staff and Nurse Practitioner interviews, the facility failed to provide effective supervision of a cognitively impaired resident (Resident #91) who was known to exhibit wandering behavior and rummaging. This failure resulted in Resident #91 obtaining and ingesting one gel capsule of an over-the-counter cold and flu medication containing acetaminophen, dextromethorphan (cough suppressant) and phenylephrine (nasal decongestant) that was in an unlocked drawer in the receptionist's desk located in the lobby area of the facility. This deficient practice was identified for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #91).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to discard expired medications and record an opened date on ophthalmic drops that had shortened expiration dates on 2 of 6 medication carts that were reviewed for medication storage (200 hall medication cart #1 and medication cart #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the facility assessment identified and addressed the care required for the population of residents with a port-a-cath (a small implanted device placed under the skin in the chest to provide easy, long-term access to a vein for chemotherapy, medication, intravenous (IV) fluids, or blood sampling), and to address the staff training necessary to competently provide port-a-cath care for residents for 1 of 1 resident (Resident #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage a day, 7 days a week for 13 of 139 days reviewed.

Inspectors wroteBased on observations, record review, and Consulting Pharmacist and staff interviews, the facility failed to administer the physician ordered hypotensive medication (a medication to increase blood pressure) 6 times in one month when the blood pressure reading required the administration of the medication for 1 of 3 residents (Resident #18) sampled for medication review.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 2 of 4 residents reviewed for abuse (Resident #35 and Resident #78). On 08/28/24 Resident #35 attempted to grab belongings out of Resident #84's hat, Resident #84 told him to stop but he continued. In response, Resident #84 grabbed Resident #35 by the arm and shook him causing Resident #35 to fall to the floor. Resident #84 then attempted to run Resident #35 over with his wheelchair. Resident #35 was not injured. On 09/23/24 Resident #78 entered Resident #76's room and Resident #76 slapped Resident #78 on the left cheek with an open hand and Resident #78 sustained mild redness to her left cheek which resolved within minutes after being assessed.

Inspectors wroteBased on record review, and Resident Representative (RR), Hospital Case Manager, Psychiatric Provider, and staff interviews, the facility failed to permit a resident to return to the facility after being transferred to the hospital for evaluation due to a resident to resident altercation for 1 of 1 resident reviewed for hospitalization (Resident #84).

Inspectors wroteBased on observations, record review, and Consulting Pharmacist, Nurse Practitioner and staff interviews, the facility failed to a) clarify a physician's order for 26 days to determine the right dose to be administered for a daily topical medication to manage pain related to osteoarthritis (degeneration of bone that can cause pain) for Resident #60, b) follow the physician's orders to remove a lidocaine patch (medicated topical pain patch) after 12 hours of use to prevent potential skin irritation, redness, swelling, and/or discomfort for Resident #67 and c) to administer the correct ordered dose of a supplemental medication three times for Resident #18. This was for 3 of 3 residents sampled for medication review.

Inspectors wroteBased on observations, record review, and resident and staff interview the facility failed to secure a resident's indwelling urinary catheter tubing to prevent tension or trauma for 1of 1 resident reviewed for urinary catheter (Resident #54).

Inspectors wroteBased on observations, record review, and Dialysis Nurse and staff interviews, the facility failed to follow the physician's orders to remove a dressing to an arterial venous fistula (a surgically created connection between artery and vein in the arm used for dialysis treatments) one hour after dialysis treatment to monitor for bleeding at the access cite and to prevent potential damage to the access cite for 1 of 2 residents (Resident #69) reviewed for dialysis.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to ensure it was free of medication error rates greater than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 1 of 3 residents (Resident #60) observed during medication administration preparation.

Inspectors wroteBased on observations and staff interviews the facility failed to discard expired opened multidose medications for 2 of 4 medication carts reviewed (300 and 400-hall medication carts).

Inspectors wroteBased on observations, record review and staff interviews, the facility inaccurately documented the removal of a lidocaine patch (medicated topical pain patch) and the presence of a fall mat for 1 of 3 residents (Resident #67) observed during a medication pass, and inaccurately documented the removal of a dressing to an arterial venous access (vascular access to arm used for dialysis treatments) for 1 of 2 residents (Resident #69) observed for dialysis.

Inspectors wroteBased on observations, record review, and staff interviews, facility staff failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 and Nurse #3 failed to apply a gown before entering residents' room to provide care for 2 of 2 residents (Resident #40 and Resident #12). The deficient practice occurred for 2 of 2 staff members observed for infection control practices.

Inspectors wroteBased on record review, staff interviews, Consultant Pharmacist and Psychiatrist interviews, the facility failed to 1.a) provide an indication for an antipsychotic medication (Thiothixene-prescribed for treatment of Schizophrenia) b) complete an Abnormal Involuntary Movement Scale (AIMS) assessment which is used for medication monitoring to assess for side effects of antipsychotic medications for 1 of 5 residents (Resident #41). 2) Include a stop date for an as needed psychotropic medication for 1 of 5 residents (Resident # 42 ) reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interviews the facility failed to administer the pneumococcal vaccine after obtaining informed consent for 4 of 5 residents (Resident #7, #6, #1, #16) and offer and obtain consent for 1 of 5 residents (Resident #24) reviewed for immunizations.

Inspectors wroteBased on record review and staff interviews the facility failed to complete comprehensive assessments within the 14-day required timeframe for 3 of 15 residents (Resident #17, Resident #42, and Resident #5) reviewed for comprehensive Minimum Data Set (MDS) assessments.

Inspectors wroteBased on record review, staff interviews, Medical Director, and Psychiatrist interviews, the facility failed to initiate psychiatric services according to the level 2 PASRR (Preadmission Screening Resident Review - a required screening to ensure residents with serious mental illness, intellectual, or developmental disabilities received appropriate placement and services) for 1 of 3 residents (Resident #1) reviewed for PASRR compliance.

Inspectors wroteBased on observations, staff interviews, and Pharmacy Consultant interviews the facility failed to store controlled substances in a permanently affixed compartment of the refrigerator in the only medication storage room currently in use at the facility.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to maintain an accurate Medication Administration Record (MAR) for 1 of 16 residents (Resident #205).

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to follow the manufacturer's guidelines for cleaning and disinfection of a blood glucose meter which was stored in the medication cart after use for 1of 1 resident observed for blood glucose monitoring (Resident #205).

Inspectors wroteBased on staff interviews, record review, and Ombudsman interview the facility failed to notify the Regional Ombudsman of discharge to the hospital for 2 of 2 residents reviewed for discharge (Resident #34, Resident # 41).