West Carroll Care Center, Inc

Inspectors wroteBased on record reviews, interviews, and observations, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 (#22) of 1 resident sampled for urinary catheter. The facility failed to document intake and output records, document character and consistency of urine daily, and report unusual appearance of urine/signs and symptoms of a urinary tract infection to the Director of Nursing (DON) and physician immediately for Resident #22.

Inspectors wroteBased on record reviews, interviews, and observations, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible for 1 (#47) of 4 (#3, #6, #35, and #47) residents sampled for nutrition. The facility failed to document meal intake for each meal and update care plan with a significant weight loss for Resident #47.

Inspectors wroteBased on record reviews, interviews, and observations, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (#6) of 1 resident sampled for dialysis. The facility failed to document intake and output records as specified in plan of care for Resident #6.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The facility had excessively low weekend staff during Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025.

Inspectors wroteBased on record review and interview the pharmacist failed to identify and report irregularities to the physician and DON (Director of Nursing) for 1(#39) of 5 (#1, #2, #38, #39, #47) residents reviewed for unnecessary medications. The pharmacist failed identify irregularities for Resident #39. Resident #39 was not being monitored for signs and symptoms of bleeding while receiving an anticoagulant medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure that each resident was free from unnecessary medication use for 1 (#39) of 5 (#1, #2, #38, #39, #47) residents reviewed for unnecessary medications. The facility failed to monitor Resident #39 for signs and symptoms of bleeding while receiving an anticoagulant medication.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (# 45) of 1 sampled residents reviewed for environmental concerns. The facility failed to ensure that the resident's air conditioning vent remained clean and free of mold like substance.

Inspectors wroteBased on record review and interview the facility failed to electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to Centers for Medicare and Medicaid (CMS) in a timely manner for 1 (#43) of 2 (#11, #43) residents reviewed for the completion of a seven day discharge assessment.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 (#71) of 1 (#71) resident reviewed for respiratory care. The facility failed to ensure Resident #71's nebulizer tubing and t-piece was properly stored in a plastic bag.

Inspectors wroteBased 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. On 01/28/2025, it was determined that the resident had obtained a left displaced femoral neck fracture, which required surgical repair on 01/29/2025. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (#5) of 3 (#5, #6, and #61) residents reviewed for nutrition. The facility failed to document the supper meal intake percentages daily for resident #5.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that nursing staff are able to demonstrate competency in skills necessary to care for resident needs for 1 (#5) of 5 (#3, #5, #15, #40 and #62) residents records reviewed. The facility failed by not having documentation of sites for administration of insulin.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#3) of 4 (#3, #37, #62, #68) residents on Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing incontinent care to Resident #3 who was on Enhanced Barrier Precautions.

Inspectors wroteBased 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. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 05/06/2024. It was determined to be a Past Noncompliance Citation.

Inspectors wroteBased 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. It was determined to be a Past Noncompliance Citation.

Inspectors wroteBased 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. (9 hours and 44 minutes). [...]

Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents' medical records contained accurate documentation of care provided in accordance with accepted professional standards and practices for 3 (#1, #2, and #3) of 3 sampled residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to revise and implement a comprehensive person-centered care plan for 2 (#1 & #52) of 20 sampled residents. The facility failed to revise the plan of care for resident #1 related to edema. The facility failed to provide 2 person assistance with activities of daily living for resident #52.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#32) of 1 (#32) sampled resident reviewed for positioning and mobility. The facility failed to provide maintenance or restorative therapy for Resident #32's left hand contracture.

Inspectors wroteBased on record review and interview, the facility failed to implement the facility's abuse policy by not suspending S4 Certified Nurse Assistant (CNA) immediately following an allegation of physical abuse for 1 (#52) of 4 (#7, #43, #52, and #54) sampled residents reviewed for abuse.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#10) of 1 residents reviewed for skin conditions. The facility failed to assess and treat skin conditions for resident #10.