Carroll House

Inspectors wroteBased 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. The facility census was 56. The Administrator was notified on 7/11/2025 at 2:30P.M. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview, and record review, the facility failed to investigate an allegation of abuse when (Resident #18) reported to facility staff he/she had been abused by LPN A 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 facility census was 56. Review of the facility's undated Abuse and Neglect policy showed:- Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. [...]

Inspectors wroteBased 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. The facility census was 53. Review of the facility's Safe Food Handling Policy, dated 5/20/15, showed: -All food items should be stored and tightly sealed with an identifying label and date. [...]

Inspectors wroteBased 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. showed: -Multiple younger residents moving from table to table; -Multiple residents with their abdomen showing and upper buttocks showing; - Multiple residents yelling back an forth at each other and yelling at the kitchen; [...]

Inspectors wroteBased 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. The facility supports the resident's right to refuse a room change made solely for the staff's convenience. [...]

Inspectors wroteThe facility failed to provide a comfortable and home -like environment for four of 20 sampled residents ( Resident #2, #11, #22 and #24) when they failed to ensure sound levels were not loud and uncomfortable in the dining room, when a resident was yelling and staff failed to intervene, and when the facility failed to ensure the door to the smoking area did not slam shut when residents went in and out and caused distress for one resident (resident #24). The facilty census was 53. Review of the facility's undated Resident Rights Policy showed: -The resident shall be treated with consideration and respect and full recognition of their dignity and individual preferences. The facility did not provide the requested policy regarding a comfortable and homelike environment. 1. Observation on 5/27/24 at 12:22 P.M. showed: -Multiple younger residents moving from table to table; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure resident Minimum Data Set assessments were completed accurately and timely for three of 14 sampled residents (Residents #177, #78 and #80 ). The facility census was 53. Review of the facility provided Minimum Data Set and Care Planning Guidelines, dated 10/1/2015 included; It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published Interim RAI manual errata documents and applicable federal guidelines as the authoritative guide for completion of the MDS, CAAs and resident care planning. 1. Review of Resident #177's face sheet showed: - The resident admitted to the facility on [DATE]; - Diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of 14 sampled residents (Residents #8, #78 and #80). The census was 53. Review of the facility provided Minimum Data Set and Care Planning Guidelines, dated 10/1/2015 showed: It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published Interim RAI manual errata documents and applicable federal guidelines as the authoritative guide for completion of the MDS, CAAs and resident care planning. 1. Review of Resident #8 admission MDS 5/1/24 showed: -admission date of 4/24/24; -Brief Interview of Mental Status (BIMS) of 14, indicated No cognitive deficits. [...]

Inspectors wroteBased on record review and interview, the facility failed to review and update their facility-wide assessment to determine what resources are necessary to care for their residents competently during day to day operations and emergencies. The facility census was 53. The facility did not provide the requested policy regarding maintaining a facility assessment. 1. Review of the facility's 802/Matrix (a tool used by facilty staff to identify pertinent care areas for residents living in the facilty), dated 5/27/24 showed: -32 residents with behavior health needs; -The facilty census was 53. Review of the facility assessment, provided by the facility, showed: -The name of the administrator was incorrect; -Assessment review date with the Quality Assurance and Assessment/ Quality Assurance and Performance Improvement (QAA/QAPI) committee was 12/14/22; -Annual review date was 2/2/23; [...]

Inspectors wroteBased on observation and interviews the facility failed to maintain infection control when two of 14 sampled resident's (Resident #177 and #178), nebulizer machines (a machine that turns liquid medication into a mist and is inhaled) and tubing were resting on the floor without a barrier. Additionally Resident #178's continuous positive airway pressure (CPAP) mask was observed resting on the floor and not on a barrier. The facility census was 53. The facility did not provide a policy regarding placement of nebulizer machines and CPAP mask's. 1. Review of Resident #177 record showed the following: -The resident was admitted to the facility on [DATE]; - Diagnoses included: Chronic obstructive pulmonary disease (COPD, a group of diseases that affects breathing), cough, and anxiety; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide nurse aide's annual individual performance review or evaluation and competency,and failed to implement a tracking system for monitoring training hours. This effected two of two sampled nurse aides (Certified Nurse Aide; (CNA) D and CNA E) and had the potential to effect all staff and residents. The facility's census was 53. The facility did not provide a policy on education and competency. 1. Record review of the in-service records for CNA D showed: - A hire date of 6/15/2021; -Had less than twelve hours of in-service education per year; -No annual competency for 2023. 2. Record review of the in-service records for CNA E showed: -A hire date of 11/3/2023 with a previous hire date of 4/10/2014; [...]

Inspectors wroteBased on interview and record review, the facility failed to clarify the status of the Resident #11's Do Not Resuscitate Order (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) when the resident's responsible party signed the revocation provision of the DNR, with out changing the order on the resident's Physician's Order Sheet (POS) to Full Code Status. This affected one resident (Resident #11). The facilty census was 53. Review of the facilty's Advanced Directive Policy, dated March 2015, showed: -The social services designee will inquire of the resident and/or his/her family members about the existence of any written advanced directives information; -Advanced directive shall be displayed prominently in the medical record under the advanced directive tab. 1. Review of the resident's DNR showed: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to train staff to adequately care for one resident (Resident #179) with behavioral health care needs, causing Resident #22 to feel unsafe within the facility. The facility census was 53. The facility did not provide a policy on education and competency. Review of education records for Certified Nurse Aide (CNA) A and B for August 2023-May 2024 showed no education on psychiatric illness and interventions. 1. Review of Resident #179 medical record showed: -admitted on [DATE]; -Diagnoses of: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident to resident altercation that was investigated as abused was reported to the Department of Health and Senior Services (DHSS) within the required two hour time frame when Resident 1 slapped Resident #2 in the face on 12/18/23. The facility census was 21. Review of the reporting abuse and neglect policy dated November 2016 showed: - The facility staff were to report abuse allegations to DHSS within two hours after the allegation was made; - All employees of the facility are mandated reporters of abuse and neglect; - All allegations of abuse will meet the two hour reporting timeframe requirement even if it occurs during night shift, on the weekend, or during a holiday. 1. [...]

Inspectors wroteBased on interview and record review, the staff failed to ensure the physician signed the resident's purple Outside of Hospital Do Not Resuscitate (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, CPR, if the resident's breathing sops or if a resident's heart stops beating) for one of eight sampled residents, (Resident #1) and failed to ensure two physicians signed the incapacitation form for Resident #8 and #5. The facility census was 16. Review of the facility's undated policy for advance directive showed, in part: - The facility will respect advance directives in accordance with state law; - Upon admission of a resident, the social services designee will inquire of the resident, and /or his/her family members, about the existence of any written advance directives; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary notice of Non-coverage (SNF ABN), CMS-10055 for two sampled residents (Resident #3 & 16). The facility census was 16. Review of undated facility policy showed: -Please refer to Medicare claims Processing Manual, chapter 30 for general notice rquirements and detailed information about SNFABN. Information on the ABN (Form CMS-R-131) can be found on the ABN webpage: http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html -A.) SNF's will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. -Completing the SNFABN -The SNFABN is available for download by selecting the 'FFS SNFABN' link from the menu on the wepage http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assure residents have the right to file grievances in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievances, the right to obtain a written decision regarding his or her grievance. This had the ability to affect all residents. The facility census was 16. Review of the facility policy for grievance protocol showed: -Purpose of the Grievance/complaint Report and Grievance Log is to provide a written record on each resident and family concern and to insure proper follow-up through the appropriate discipline. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided written notice of transfer or discharge to residents or their responsible party and the reasons for the transfer in writing in a language they understood. This affected two of eight sampled residents, ( Resident #8 and #5). The facility census was 16. Review of the facility's undated policy for discharge/transfer of a resident, showed, in part: - The purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Explain transfer and reason to the resident and /or representative and give copy of signed transfer or discharge notice to the resident and /or representative or person responsible for care. NOTE: if emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a bed hold policy to residents or their responsible party when staff transferred two of eight sampled residents, (Resident #8 and #5) to the hospital. The facility census was 16. Review of facility's undated bed hold guidelines, showed, in part: - This facility will notify all residents and /or their representative of the bed hold guidelines; - This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave. 1. Review of Resident #8's progress notes, dated 7/25/22 showed: - 12:02 A.M., upon entering the resident's room observed the resident to be lying face down on blankets on the floor. The resident had a bloody nose with swelling and redness to nose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop individualized person centered comprehensive care plans for two residents (Resident #2 and #9) to address vision changes for Resident #2 and the use of Warfarin (blood thinner) for Resident #9 out of 8 sampled residents. The facility census was 16. Review of the facility's undated policy for comprehensive care plans, showed, in part: - An individualized comprehensive care plan that includes measurable goals and tine frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; - The interdisciplinary care plan team with input from the resident, family and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to update three (Resident #5, #15, and #16) of 8 sampled residents' care plans with new interventions that included measurable objectives and time frames to meet his/her needs after two resident's had falls (Resident #5 and #15) and one resident's fluid restrictions (Resident #16). The facility's census was 16. Review of the facility's Policy for use of comprehensive care plans showed: - It is the policy of the facility to develop and utilize comprehensive care plans that include measurable goals and time frames that meet the resident's highest practicable physical, mental and psychosocial well-being and that identify the highest level of functioning the resident may be expected to attain. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an environment free from accident hazards when staff did not implement interventions to prevent falls for two of 8 sampled residents (Resident #5 and #15) who was at risk for falls and who had both experienced multiple falls with injuries. The facility census was 16. Review of the facility's Policy Fall Precaution & Management Program and Guidelines showed: -the objective is to identify residents at significant risk of falls and provide for additional precautions to reduce and manage risk; - a resident will be placed in the Fall Precaution Program when any of the following condition exist: a. Fall Risk Assessment score on John Hopkins Fall Risk Assessment Took is 6 or greater or as identified by the specific fall risk tool used; b. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN), other than the Director of Nursing (DON) , for eight consecutive hours per day, seven days a week based on the daily staffing sheets and over the third quarter, to include weekends and week days. The facility census was 16. The facility did not provide a policy for RN coverage. 1. Review of the facility's payroll based journal (PBJ) report for Quarter 3 showed: - No RN hours in the month of April, 2022 on: - Saturday, 4/2; - Sunday, 4/3; - Saturday, 4/9; - Sunday, 4/10; - Saturday, 4/16; - Sunday, 4/17; - Saturday, 4/23; - Sunday, 4/24; - Saturday, 4/30. - No RN hours in the month of May, 2022 on: - Sunday, 5/1; - Saturday, 5/7; - Sunday, 5/8; - Saturday, 5/14; - Sunday 5/15; - Saturday, 5/21; - Sunday, 5/22; - Saturday, 5/28; - Sunday, 5/29; - Monday, 5/30. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional needs of residents in accordance with established national guidelines, and failed to follow pre-determined recipes in meal preparation. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 14. -Record review of the undated Week at a Glance menus for weeks 1 through 4, provided by the Dietary Manager, showed a variety of meals that met the nutritional needs of residents in accordance with established national guidelines. The lunch meal for week 1 that was supposed to be served was listed as pork fried rice, oriental cole slaw, broccoli, margarine donut, coffee or tea. Record review showed the recipe for 25 servings of chicken pot pie is: -6 oz. margarine -7 oz. yellow onions -11 oz. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain the walking surfaces around the facility free from obstructions to ensure residents and staff could safely exit the facility to the public way in the event of an emergency. The facility had a capacity of 63 with a census of 19 at the time of the survey. 1. Observation on 12/20/22 beginning at 10:10 A.M., showed holes and uneven asphalt in the handicapped parking spot which measured approximately 5 feet by 2 inches. During an interview on 12/20/22 at 10:10 A.M., the Maintenance Director said they had been doing repairs to the parking lot and prioritized what had been repaired. During an interview on 12/20/22 at 2:00 P.M., the Administrator said the issues with the handicapped parking spot should have been repaired, but corporate only approved the repairs that had been made and that was not part of it.