The Carrolton of Fayetteville
2461 Legion Road, Fayetteville, NC 28306 · Cumberland County · 120 certified beds · avg 117 residents/day · certified since Jun 13, 1991
Part of chain: CARROLTON NURSING HOMES (6 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 3, 2018 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 11, 2018 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jul 3, 2018 · F-0695
The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 11, 2018 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 3, 2018 · F-0690
The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 11, 2018 (Deficient, Provider has date of correction)
All citations in the current public record (26)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 3, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 12, 2025 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Sep 12, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Sep 12, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Sep 12, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jun 14, 2024 | B · Minimal risk, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jun 4, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 25, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Apr 2, 2024 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Apr 2, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 3, 2018 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jul 3, 2018 | ▲ J · Immediate jeopardy, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jul 3, 2018 | ▲ G · Actual harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jul 3, 2018 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 3, 2018 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jul 3, 2018 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Jul 3, 2018 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 3, 2018 | D · Potential for harm, one-off | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. |
| Jul 3, 2018 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 3, 2018 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jul 3, 2018 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 11 | 3 | J ▲ |
| 2024 | 10 | 0 | E |
| 2025 | 4 | 0 | F |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.60 | 4.01 | 3.95 | bottom 44% in North Carolina; bottom 41% in the U.S. |
| Registered Nurse hours | 0.31 | 0.64 | 0.69 | bottom 10% in North Carolina; bottom 11% in the U.S. |
| Weekend total nurse staffing | 3.01 | 3.56 | 3.50 | bottom 28% in North Carolina; bottom 32% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.11 | 0.41 | 0.48 | bottom 2% in North Carolina; bottom 2% in the U.S. |
| Total nursing staff turnover (%) | 45.7 | 49.0 | 45.8 | top 42% in North Carolina; bottom 48% in the U.S. |
| RN turnover (%) | 61.5 | 45.7 | 42.9 | bottom 26% in North Carolina; bottom 20% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.41, RN 0.29, weekend 2.86. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| C. Saunders Roberson, Jr., as Trustee of the Judith Roberson Dixon Irr | Organization | 5% or Greater Direct Ownership Interest | 50% | 10/01/2020 |
| Figlewski, Deborah | Individual | 5% or Greater Direct Ownership Interest | 13% | 10/01/2020 |
| Powell, Earl | Individual | 5% or Greater Direct Ownership Interest | 13% | 10/01/2020 |
| Powell, John | Individual | 5% or Greater Direct Ownership Interest | 13% | 10/01/2020 |
| Russell, Denise | Individual | 5% or Greater Direct Ownership Interest | 13% | 10/01/2020 |
| Carrolton Facility Management, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2020 |
| Carrolton Facility Management, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/05/2026 |
| Khurana, Rajesh | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2020 |
| Khurana, Rajesh | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
| Roberson, Carrol | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2020 |
| Roberson, Carrol | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
| Rozier, Sonya | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2020 |
| Rozier, Sonya | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can I see where garbage is stored and how often it's removed?"
- "How do you explain health changes and treatment options to residents and their families?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Village Green Health and Rehabilitation | 2.2 mi | Fayetteville, NC | ★★★★★ | 4/5 | |
| Carolina Rehab Center of Cumberland | 3.1 mi | Fayetteville, NC | ★★★☆☆ | 2/5 | |
| Haymount Rehabilitation & Nursing Center, INC. | 4.1 mi | Fayetteville, NC | ★★★★★ | 5/5 | |
| Woodlands Nursing & Rehabilitation Center | 5.2 mi | Fayetteville, NC | ★★★★☆ | 4/5 | |
| Highland House Rehabilitation and Healthcare | 5.4 mi | Fayetteville, NC | ★★☆☆☆ | 3/5 | |
| Bethesda Health Care Facility | 5.6 mi | Eastover, NC | ★★★★☆ | 4/5 | |
| Autumn Care of Fayetteville | 6.1 mi | Fayetteville, NC | ★★★★★ | 4/5 | |
| Whispering Pines Nursing & Rehab Center | 6.4 mi | Fayetteville, NC | ★★★★★ | 5/5 | |
| Autumn Care of Raeford | 18.2 mi | Raeford, NC | ★★☆☆☆ | 3/5 | |
| Liberty Healthcare Services of Golden Years Nursin | 19.3 mi | Falcon, NC | ★★★★☆ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 345376.