The Carrolton of Lumberton

In the surveyor’s words

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

• Immediate jeopardy, patternF600Apr 6, 2023

  Based on staff and nurse practitioner interviews, observations, and record review, the facility failed to protect two vulnerable female residents right to be free from unwanted touching and intrusions into personal space by Resident #1 (Resident #6 and Resident #2). Resident #1 had severely impaired cognition, had behaviors, and was known to wander. On 3/11/23 Resident #1 was observed by Nurse #1 in Resident #6's room leaning over her bed with his hands pulling her shirt near her shoulders, their faces were inches apart, and Resident #1 had his lips pursed as though he was trying to kiss Resident #6 on her mouth. On 3/25/23 Resident #2 was heard calling out for help and when staff entered her room Resident #1 was observed naked from the waist down rubbing Resident #2's feet. […]

• Immediate jeopardy, patternF689Apr 6, 2023

  Based on observation, staff interviews, Nurse Practitioner interview, and record review, the facility failed to provide the necessary supervision to prevent accidents for a resident (Resident #1) with severe cognitive impairment, poor safety awareness, and known behaviors that included exit seeking, wandering into other residents' rooms, and physical aggression for 1 of 1 resident reviewed for accidents. On 2/16/23 Resident #1 exited the facility unsupervised and without staff's knowledge and was found 1.7 miles away from the facility. This had a high likelihood of resulting in serious harm to Resident #1. […]

• No harm, potential for more than minimal, patternF602Feb 19, 2026

  Based 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). Findings included: a.) Resident #21 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and debility. A physician's order with a start date of 10/16/23 which remained as an active order for Resident #21 revealed Tramadol 50 milligrams (mg) tablets, one tablet by mouth two times a day for pain. […]

• No harm, potential for more than minimal, patternF684Feb 19, 2026

  Based 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). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses to include personal history of traumatic brain injury with persistent vegetative state. […]

• No harm, potential for more than minimal, patternF755Feb 19, 2026

  Based 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). Findings included: a. A physician's order for Resident #69 with a start date of 8/8/25 revealed Lorazepam 0.5 milligrams (mg) tablets, one tablet by mouth every 24 hours as needed for anxiety for 14 days. […]