The Carrolton of Dunn

In the surveyor’s words

From the most serious findings on record at The Carrolton of Dunn, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Aug 21, 2026

  Based on observation, record review, and interviews with staff, Hospice Nurse, Hospice Physician, and the Medical Director, the facility failed to prevent a significant medication error when Nurse #4 incorrectly entered a physician order for morphine sulfate (a potent opioid pain medication) oral solution to administer 9.5 milliliters (mL) instead of the ordered 0.5 mL. The medication error resulted in Resident #1 being administered a 19 times greater dose of 190 milligrams (mg) of morphine sulfate oral solution instead of the ordered 10 mg per dose in two separate doses for a total of 380 mg on 8/09/26. […]

• Immediate jeopardy, isolatedF580Jun 10, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Jun 10, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF580Oct 8, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Oct 8, 2024

  Based 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. […]