West Carroll Care Center, Inc

In the surveyor’s words

From the most serious findings on record at West Carroll Care Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, widespreadF700May 17, 2022

  Based on observation, interview, and record review the facility failed to 1) assess residents with side rails for the for risk of entrapment, 2) attempt to use alternate measures prior to using side rails, 3) review the risks and benefits of side rails with residents or the residents' representative, and 4) failure to obtain an informed consent from the resident or residents' representative prior to the use of side rails. The deficient practice was identified for 5 (Resident #1, #2, #3, #4, and #5) of 5 (Resident #1, #2, #3, #4, and #5) sampled residents reviewed for side rails. […]

• Immediate jeopardy, isolatedF684Feb 18, 2025

  Based on interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to recognize, assess, intervene, and document a resident's condition after a fall to avoid delayed treatment for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for falls. This deficient practice resulted in an Immediate Jeopardy situation on 01/24/2025 at approximately 3:15 p.m., when resident #1 had a fall in his room. The resident's nurse failed to assess the resident after the fall, document the incident, and report the incident to the resident's physician and the director of nursing. […]

• Immediate jeopardy, isolatedF689May 7, 2024

  Based on record reviews and interviews, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (#1) of 5 (#1, 2, 3, 4, 5) sampled residents by failing to ensure resident #1 was safely secured in a lift chair while bathing in the whirlpool room. This deficient practice resulted in an Immediate Jeopardy situation that began on 04/30/2024 at 9:15 a.m., when resident #1 was not properly secured with the seat belt in a lift chair while receiving a whirlpool bath. The resident fell from the chair to the floor and sustained a fractured skull, fractured left arm, laceration to the left side of the head and a brain bleed. […]

• Immediate jeopardy, isolatedF689Apr 25, 2024

  Based on observations, record reviews and interviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4 and #5) residents who was assessed at risk for elopement, was adequately supervised to prevent her from eloping from the facility. This deficient practice resulted in an Immediate Jeopardy situation on 04/19/2024 at approximately 6:20 p.m. when resident #1 (a severely cognitively impaired resident identified as an elopement risk) was found approximately 300 yards outside of the facility by a staff member. Resident #1 was located 10 minutes after she eloped on 04/19/2024 through a facility door and was returned to the facility at approximately 6:32 p.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 04/24/2024. […]

• Immediate jeopardy, isolatedF600Jan 3, 2024

  Based on interviews and record reviews, the facility failed to protect the residents' right to be free from neglect by staff failing to provide the care needs every two hours as indicated in the care plan for 3 (#1, #2, and #3) of 3 (#1, #2, and #3) residents reviewed for neglect. This deficient practice resulted in an immediate jeopardy situation on [DATE] at 10:13 p.m. (two hours after resident #1 was last seen) when staff failed to make rounds every two hours on resident #1, who was on oxygen and was dependent on staff for transfers, toileting, and bed mobility. Video surveillance revealed the resident was administered medications on [DATE] at 8:13 p.m. by S3LPN (Licensed Practical Nurse) and no staff rounded on the resident or entered the resident's room until [DATE] at 5:57 a.m. […]