Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carroll House during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to provide residents with access to the Missouri abuse and neglect hotline using facility phones, as all attempts to call the hotline from these phones were unsuccessful while personal cell phones worked. Multiple residents with varying medical and psychiatric conditions were unable to make confidential calls to the hotline, despite reporting the issue to staff. Facility leadership and staff were also unable to connect to the hotline using facility phones, and the problem persisted across several days and devices.
The facility's kitchen was found to be unsanitary, with dust-covered vents, overflowing trash, and outdated food items. Hazardous chemicals were stored with food, and the dishwasher sanitation log was incomplete. Staff interviews revealed confusion over responsibilities for cleaning and maintenance, contributing to these deficiencies.
The facility failed to maintain a dignified environment for residents, allowing younger residents to expose bare skin and create a loud, chaotic atmosphere in common areas. This affected several residents with cognitive impairments, causing discomfort and anxiety. The facility's policy on resident dignity and respect was not upheld, as acknowledged by the administrator.
The facility failed to provide written notice to four residents before room changes, causing emotional distress. Residents were moved without receiving the required written explanation or choice, contrary to the facility's policy. The administrator acknowledged the oversight, as documented in the nurses' notes.
The facility failed to maintain a homelike environment due to loud noise levels in the dining room and a slamming door to the smoking area, causing distress among residents with cognitive impairments and anxiety. Staff lacked training to manage these situations, leading to inaction and discomfort for residents, some of whom considered leaving the facility.
The facility failed to complete timely and accurate MDS assessments for three residents, each with multiple diagnoses, including schizoaffective disorder and Alzheimer's disease. Interviews with the MDS Coordinator, DON, and Administrator confirmed that the required assessments were not completed within the mandated timeframe, indicating non-compliance with facility policy and federal guidelines.
The facility failed to provide complete and individualized care plans for three residents, each with complex medical conditions such as diabetic foot ulcers, schizoaffective disorder, and Alzheimer's disease. Despite the facility's policy to complete MDS assessments within 14 days and care plans within 7 days thereafter, these were not documented, leading to a deficiency in care planning.
The facility did not update its facility-wide assessment to reflect current conditions, including a change in administrator and an increase in residents with behavioral health needs. The assessment contained outdated and incorrect information, such as the average daily census and the number of residents with behavioral health needs. The administrator admitted the assessment should be updated within seven to fourteen days after changes.
Two residents' nebulizer machines and CPAP masks were found resting on the floor without barriers, due to the absence of tables for storage. The facility lacked a policy for proper placement of these items, and the Infection Preventionist and DON acknowledged the need for elevated storage. Both residents did not have a care plan or MDS completed, contributing to the infection control deficiency.
The facility failed to provide the required twelve hours of in-service education per year and did not conduct annual competency evaluations for two CNAs, affecting all staff and residents. The newly appointed Administrator and DON acknowledged the need for training, particularly in psychiatric care, but there was no existing tracking system for staff education.
A facility failed to update a resident's Physician's Order Sheet to reflect the revocation of a DNR order, despite the responsible party signing the revocation. The resident, with moderate cognitive impairment and a history of heart failure, was still listed as DNR in the care plan. The administrator acknowledged the oversight, noting that social services should ensure the accuracy of DNR orders.
A facility failed to train staff on managing psychiatric conditions, leading to a resident with behavioral health needs causing distress to another resident. The staff did not intervene due to a lack of training, and the facility lacked a policy on education and competency. The Administrator and DON acknowledged the need for training but were unsure of the current education status.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Residents Access to State Abuse Hotline via Facility Phones
Penalty
Summary
The facility failed to ensure that residents had the ability to make confidential phone calls to the Missouri abuse and neglect hotline. Multiple observations and interviews revealed that the phones provided by the facility, including hand-held and desk phones accessible to residents, were unable to successfully connect to the hotline. When attempts were made to call the hotline from these facility phones, the calls would drop after a partial ring, and this issue persisted across several days and multiple devices within the facility. In contrast, calls made to the hotline from personal cell phones were successful, indicating the problem was specific to the facility's phone system. Three residents were directly affected by this deficiency. One resident, who was cognitively intact and independent in activities of daily living, reported being unable to use the facility phone to call the hotline and was not permitted to have a personal cell phone due to guardian restrictions. Another resident, with diagnoses including schizophrenia, bipolar disorder, and depression, also reported being unable to reach the hotline despite multiple attempts and expressed frustration, especially after an incident involving a broken knee. A third resident, with post-traumatic stress disorder and intact cognition, similarly reported being unable to use the facility phones to call for help and felt helpless as a result. All three residents had communicated these issues to staff, but no corrective action was taken prior to the survey. Facility leadership, including the Administrator, Assistant Director of Nursing, and Director of Nursing, attempted to use the facility phones to call the hotline during the survey and were also unsuccessful. Staff interviews confirmed that the issue had been reported by residents but not escalated appropriately. The facility's own policy stated that residents have the right to confidential communication and to voice grievances without interference, but the inability to access the hotline via facility phones directly contravened these rights.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during a survey. The kitchen had several issues, including an open package of noodles, vents covered with dust and debris, and an overflowing trash can with food particles. Additionally, there were empty cardboard boxes, a fan covered with dirt, a bucket with black liquid, and a mop next to a food storage rack. The floor in the dry storage room was dirty and sticky, and there were hazardous chemicals stored alongside food items. The dishwasher sanitation log was incomplete, with no entries recorded on several dates. Interviews with staff revealed a lack of clarity and responsibility regarding kitchen cleanliness and maintenance. The Dietary Manager indicated that maintenance was responsible for cleaning the vents, but maintenance staff were unaware of this duty and had not received any work orders for vent cleaning. The Registered Dietitian and the Administrator both expected the kitchen to be clean and free of clutter, with proper food storage and regular checks of the dishwasher sanitizer. However, these expectations were not met, leading to the observed deficiencies.
Failure to Maintain Resident Dignity and Appropriate Environment
Penalty
Summary
The facility failed to provide a dignified existence for three residents when it allowed multiple residents to remain in common areas with bare skin exposed without staff intervention. Observations showed younger residents moving from table to table with their abdomens and upper buttocks exposed, yelling at each other and at the kitchen staff. This environment was not conducive to the needs of the geriatric residents, who remained seated and were subjected to the loud and chaotic atmosphere. The facility's Resident Rights Policy mandates that residents be treated with consideration and respect, recognizing their dignity and individuality, which was not upheld in this situation. Resident #2, with severe cognitive impairment and receiving hospice services, was affected by the loud and busy environment, causing concern for their responsible party about the resident's comfort and safety. Resident #11, with moderate cognitive impairment and anxiety, expressed discomfort with the noise and inappropriate dress of the new residents, leading to increased anxiety and a reluctance to visit the dining room. Resident #24, also with moderate cognitive impairment, felt disrespected by the exposed skin of the new residents and reported a fight in the dining room, contributing to a sense of insecurity and discomfort in what should be their home. The facility administrator acknowledged that residents should be dressed appropriately and treat each other with respect, indicating a failure to enforce these expectations.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to adhere to its policy regarding room changes, resulting in a deficiency related to the residents' rights to receive written notice before a room change. Four residents were moved to different rooms without receiving the required written notice, which included the reason for the move. This oversight led to emotional distress among the affected residents, as they were not given a choice or adequate time to prepare for the move. The facility's policy, dated 2017, emphasizes the importance of providing written notice and considering residents' preferences, but this was not followed in these instances. Resident #3, who had no cognitive deficits and was moderately dependent on staff for activities of daily living, was moved without written notice. The resident expressed distress over the move, which was communicated verbally by the Assistant Director of Nursing. Similarly, Resident #2, who had severe cognitive impairment and was receiving hospice services, was moved without written notice. The resident's responsible party was only informed by phone, and no choice was offered regarding the room change. Resident #11, with moderate cognitive impairment and anxiety, was also moved without written notice. The resident and their family were informed by phone, but no written documentation was provided. Resident #24, who had moderate cognitive impairment and was occasionally incontinent, was moved with only verbal notice given to the resident and their family. The facility's administrator acknowledged that written notice should have been provided, as documented in the nurses' notes, but this was not done for the residents involved.
Facility Fails to Maintain Homelike Environment Due to Noise Issues
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for several residents, as evidenced by loud and uncomfortable sound levels in the dining room and issues with a slamming door to the smoking area. Observations showed multiple residents yelling at each other and at kitchen staff, with staff failing to intervene. This environment was particularly distressing for residents with cognitive impairments and anxiety, such as Resident #2, who required a calm environment to avoid overstimulation, and Resident #11, who expressed increased anxiety and discomfort due to the noise and new residents. Resident #22, who also had moderate cognitive impairment, was observed to be distressed by the noise in the dining room, which led to increased anxiety and refusal to eat. Staff members admitted to lacking training on how to handle situations involving mental health residents, contributing to their inaction during these incidents. The facility's failure to address these issues resulted in a non-homelike environment, causing distress among residents and prompting some to consider leaving the facility. Additionally, Resident #24 was disturbed by the frequent slamming of the door to the smoking area, which was located near their room. Despite expressing concerns to the staff, no action was taken to address the issue, leading to ongoing distress for the resident. The facility's administrator acknowledged the expectation of maintaining peaceful and quiet areas but admitted that the staff's efforts to manage noise levels were insufficient, further contributing to the uncomfortable environment for the residents.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately and timely for three residents. Resident #177, who was admitted with multiple diagnoses including schizoaffective disorder and diabetes mellitus, had no completed MDS or care plan in their medical record. Similarly, Resident #78, admitted with conditions such as schizoaffective disorder and Parkinson's disease, also lacked a completed MDS and care plan. Resident #80, with diagnoses including Alzheimer's disease and kidney failure, had an entry tracking record but no completed MDS or care plan in their chart. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator revealed that admission MDS assessments should be completed within 14 days and submitted within 21 days. The DON and Administrator confirmed that residents admitted on specific dates should have had completed MDS assessments, which were not present. This indicates a failure in adhering to the facility's policy and federal guidelines for timely and accurate completion of MDS assessments and care planning.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents had complete, accurate, and individualized care plans to address their specific needs. This deficiency was identified for three residents out of a sample of fourteen. Resident #8, who was admitted on May 1, 2024, had multiple diagnoses including diabetic foot ulcers, fractures, anxiety disorder, depression, COPD, and more. Despite these complex medical conditions, there was no comprehensive care plan documented in the medical record. Similarly, Resident #78, admitted on May 7, 2024, with diagnoses such as schizoaffective disorder, Parkinson's disease, and morbid obesity, also lacked a completed Minimum Data Set (MDS) and care plan in their chart. Resident #80, admitted on an unspecified date, had conditions including Alzheimer's disease, Parkinson's disease, and kidney failure. Like the other residents, there was no completed MDS or care plan in the medical record. Interviews with the MDS Coordinator, Director of Nursing, and Administrator revealed that the facility's process requires the MDS to be completed within 14 days of admission and care plans within 7 days thereafter. However, this process was not followed, resulting in the absence of necessary care plans for the residents in question.
Failure to Update Facility-Wide Assessment
Penalty
Summary
The facility failed to review and update their facility-wide assessment to accurately determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The facility's census was 53, with 32 residents having behavioral health needs. However, the facility assessment provided was outdated and contained incorrect information, such as the name of the administrator, the average daily census, and the number of residents with behavioral health needs. The assessment had not been updated since the last review dates of 12/14/22 and 2/2/23, despite recent changes at the facility, including a change of administrator. The administrator acknowledged that the facility assessment should be updated within seven to fourteen days after such changes and that it is their responsibility to ensure regular reviews and updates.
Infection Control Deficiency: Improper Storage of Medical Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents, as observed by surveyors. Resident #177's nebulizer machine and tubing were found resting directly on the floor without a barrier. The resident mentioned that the floor was the most convenient place to store the nebulizer due to the absence of a table. Similarly, Resident #178's nebulizer machine, tubing, and CPAP mask were also observed on the floor without a barrier. The resident confirmed that the lack of a table led to storing these items on the floor. The facility did not have a policy regarding the placement of nebulizer machines and CPAP masks, contributing to the deficiency. The Infection Preventionist stated that these items should be off the floor and stored on an elevated surface, wrapped in a disposable bag. The administrator and DON also acknowledged that nebulizer machines, tubing, and CPAP masks should not be placed on the floor. The absence of a care plan and Minimum Data Set (MDS) for both residents further highlights the facility's oversight in ensuring proper infection control measures.
Deficiency in Nurse Aide Training and Competency Evaluation
Penalty
Summary
The facility failed to ensure that nurse aides received the required twelve hours of in-service education per year, did not conduct annual individual performance reviews or competency evaluations, and lacked a tracking system for monitoring training hours. This deficiency affected two sampled CNAs, D and E, and had the potential to impact all staff and residents, with the facility's census being 53. CNA D, hired on 6/15/2021, had less than the required twelve hours of in-service education per year and no annual competency for 2023. Similarly, CNA E, with a hire date of 11/3/2023 and a previous hire date of 4/10/2014, also had less than twelve hours of in-service education and no annual competency. During an interview, the newly appointed Administrator and DON, both of whom started a week prior, acknowledged the need for staff training, particularly in dealing with psychiatric illnesses and behaviors. The Administrator mentioned that RN A provides educational booklets for staff, and both the DON and Administrator plan to track training. However, there was no existing tracking system for individual staff education and competency.
Failure to Update DNR Status in Medical Records
Penalty
Summary
The facility failed to update the Physician's Order Sheet (POS) to reflect the revocation of a Do Not Resuscitate (DNR) order for a resident, despite the responsible party signing the revocation provision. This oversight resulted in a discrepancy between the resident's care plan, which still indicated a DNR status, and the actual revocation of the DNR order. The facility's Advanced Directive Policy requires that any changes to a resident's advanced directives be prominently displayed in the medical record, but this was not adhered to in this case. The resident in question had moderate cognitive impairment and required supervision for activities of daily living (ADLs). The resident's medical history included heart failure, high blood pressure, and high cholesterol. During an interview, the facility's administrator acknowledged that the social services department is responsible for ensuring the accuracy of DNR orders and that any discrepancies should be clarified. However, the absence of the social services designee on the day of the interview left the issue unresolved, highlighting a lapse in the facility's adherence to its own policies regarding advanced directives.
Lack of Staff Training on Psychiatric Care Leads to Resident Distress
Penalty
Summary
The facility failed to adequately train its staff to care for a resident with behavioral health care needs, resulting in another resident feeling unsafe. Resident #179, who has diagnoses of Bipolar Disorder, PTSD, and Autism, was observed pacing and yelling loudly in the dining area, causing distress to Resident #22, who has cerebral palsy and anxiety. The staff, including CNAs A and B, did not intervene or respond to Resident #179's behavior due to a lack of training in managing psychiatric conditions. This inaction led to Resident #22 being upset and needing to be taken to their room. The facility did not have a policy on education and competency, and the education records for CNAs A and B showed no training on psychiatric illness and interventions. Interviews with the CNAs revealed that they had not received any training on handling residents with psychiatric conditions, and they were unsure how to respond to Resident #179's behavior. The Administrator and DON acknowledged the need for staff training in dealing with agitated residents and psychiatric disorders, but there was uncertainty about the education completed by the staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 23 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Carrollton | 1.1 mi | ★★★★★ | 3 | 0 |
| Apple Ridge Care Center | 10.4 mi | ★★★★★ | 5 | 0 |
| Brunswick Health Care Center | 19.1 mi | ★★★★★ | 0 | 0 |
| Golden Age Nursing Home | 23.1 mi | ★★★★★ | 12 | 0 |
| Living Center, The | 23.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.