Carroll House

In the surveyor’s words

From the most serious findings on record at Carroll House, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 14, 2025

  Based on observation, interview, and record review, the facility failed to protect two resident's (Resident #18 and Resident #7) right to be free from physical abuse. On 6/15/25 LPN A followed Resident #18 into an unoccupied resident room rolled him/her out of the bed onto the floor multiple times and LPN A walked the resident backwards which resulted in the resident falling and sustaining a fracture of the right tibial plateau (a break in the top portion of the shinbone near the knee joint, that often occurs due to high-energy impacts such as falls). The resident was sent to the local hospital and transferred to another hospital for surgical evaluation. In addition, staff failed to protect Resident #7's right to be free from abuse when Resident #27 hit him/her on the back of the head. […]

• No harm, potential for more than minimal, widespreadF550Jul 14, 2025

  Based on observation, interview, and record review the facility failed to protect the rights of a resident's ability to make confidential phone calls to the state abuse and neglect hotline for three of the three sampled residents, Residents #16, #109, and #18, when the facility's provided phones would not allow any outgoing call to dial the Missouri abuse and neglect hotline number. This had the potential to impact all residents of the facility who wished to make a phone call to the Missouri abuse and neglect hotline. The facility census was 56. Review of the facility's policy titled, Residents Rights, undated, showed:-Residents have the right to exercise their rights. Encouragement and assistance is provided for the exercise of the resident's right as a resident and as a citizen. […]

• No harm, potential for more than minimal, widespreadF812May 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner when floors, and vents were covered in dirt and debris, and when equipment in the kitchen was covered in dust and when the dry storage contained outdated food and hazardous chemicals and when the facilty failed to ensure the dishwasher sanitizer was checked before meal service. This could potentially impact all residents by dirt or debris coming in contact with food and food preparation areas and food being served on contaminated dishes. Additionally outdated food can be potentially hazardous due to spoilage. […]

• No harm, potential for more than minimal, patternF550May 30, 2024

  Based on observation interview and record review, the facility failed to provide a dignified existence for three residents (Resident #2, #11 and #24) when the facility allowed multiple residents to remain in common areas with bare skin exposed with no staff intervention. This affected 3 out of 20 sampled residents. The facility census was 53. Review of the facility's undated Resident Rights Policy showed in part: -The resident shall be treated with consideration and respect and full recognition of their dignity and individuality. 1. Observation on 5/27/24 at 12:22 P.M. […]

• No harm, potential for more than minimal, patternF559May 30, 2024

  Based on observation, interview, and record review the facility failed to follow their policy when the facility did not provide four residents a written notice regarding a room change, including the reason for the room change, before the facility moved the resident to another room (Resident # 3, Resident #2, Resident #11 and Resident #24), of the 14 sampled residents . These residents did not want to be moved and were emotionally upset about the room changes. The facility's census was 53. Review of the facility policy, Room Change, dated 2017 showed: -It is the policy of this facility to promote a resident's right to make choices and to promptly receive written notice of a room change or change in an assigned roommate. […]