Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Carroll Care Center, Inc during CMS and state inspections, most recent first.
A resident in an LTC facility experienced a fall that was not assessed or documented by the nursing staff, leading to a delay in treatment for a displaced femoral neck fracture. The resident, who had impaired cognitive skills and was at high risk for falls, was not properly evaluated after the incident, resulting in a delay in identifying the injury.
A facility failed to document supper meal intake percentages for a resident with severe cognitive impairment and multiple diagnoses, including dementia and diabetes. The resident was at risk for weight loss due to leaving 25% or more of food uneaten at most meals. Despite an intervention in the care plan to document food intake, there was no evidence of supper meal intake documentation for two months, as confirmed by the DON.
A facility failed to document insulin injection sites for a resident with diabetes, as evidenced by missing records in the MAR for July and August. The resident, with severe cognitive impairment and multiple health issues, required regular blood sugar monitoring and insulin administration. The DON confirmed the lack of documentation, indicating a lapse in nursing staff competency.
A CNA failed to use proper PPE while providing care to a resident on Enhanced Barrier Precautions (EBP) due to MRSA. The CNA did not wear a gown and gloves as required, and performed multiple tasks without changing gloves or washing hands, contrary to the facility's EBP policy. The Infection Control Nurse confirmed the breach in protocol.
A resident with moderate cognitive impairment and high fall risk was not properly secured in a lift chair during a whirlpool bath, resulting in a fall and severe injuries. The CNA assisting the resident failed to use the seat belt, leading to the resident's fall. Immediate medical attention was required, and the CNA was suspended during the investigation.
A resident with severe cognitive impairment and identified as an elopement risk eloped from the facility and was found 300 yards away. The resident exited through an activity room door and was returned by a staff member. The facility's policies for monitoring at-risk residents were not adequately followed, leading to the incident.
Failure to Assess and Document Resident Fall Leads to Delayed Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice when a resident experienced a fall in their room. The nursing staff did not recognize, assess, intervene, or document the resident's condition following the fall, which led to a delay in treatment. The incident involved a resident who was unable to verbally communicate effectively and had a history of behaviors such as yelling out and resisting care. The resident was at high risk for falls and required substantial assistance for daily activities. On the day of the incident, the resident fell from their bed, but the nurse on duty did not assess the resident or document the fall. The incident was not reported to the resident's physician or the director of nursing. It was only after several days that the resident was found to have a displaced femoral neck fracture, which required surgical intervention. The lack of immediate assessment and documentation resulted in a delay in identifying and treating the injury. Interviews with staff revealed that the fall was initially unreported and undocumented. The CNA who witnessed the fall did not observe any immediate injuries or complaints of pain from the resident. However, the nurse who was informed of the fall did not recall being notified or assessing the resident. This oversight and failure to follow protocol contributed to the delay in addressing the resident's injury, which was later identified through an x-ray.
Removal Plan
- Weekly body audits reviewed to determine if there were any unknown injuries or significant findings. Body audits will continue until full facility body audits are completed. Statewide Incident Management System (SIMS) report opened.
- Staff education initiated: Abuse and neglect, staff rounding requirements: CNA even hours/nurses odd hours, ensure staff using proper transfer techniques, report changes in condition, change in behavior, change in skin condition to the nurse in a timely manner and any issues identified with a resident should be assessed immediately and addressed in a timely manner.
- Investigation continues regarding resident #1's injury of unknown origin, and full facility body audits continued.
- Video footage was reviewed by S1Administrator and S2DON. The video footage supported S4 CNA's statement. S3LPN was witnessed entering the resident's room after being notified of the incident. There were no issues identified with review of the footage and routine care rounds were being provided.
- S3LPN was suspended pending investigation.
- Incidents and accidents for resident #1's hall reviewed, no injuries of unknown origin noted; no additional incidents/accidents were noted.
- QA started on reviewing nurse's notes and 24-hr report to ensure that incidents/accidents are reported, processed, and completed. QA will be done 5x a week x 8 weeks then 3x a week x 4 weeks then as needed.
- Residents that resided on resident #1's hall were assessed to identify any potential significant changes, any recent hospitalizations, or other abnormal findings and there were no concerns noted.
- Staff members who worked with resident #1 through the weekend were re-interviewed in order to gain more details regarding his care, complaints, and activity level. No signs or report of distress or pain was noted. Resident appeared to continue normal activities, including being out of bed, in day room watching television, interacting with others and meal intake was normal.
- Safety measures were assessed and found to be functioning properly. Included in these were the following: Resident #1's call light was activated, the light lit up in the hall and at the switchboard (the clerk at the desk and nurse in the room could clearly hear each other speaking). Wedge cushion was in place and properly fit the resident's wheelchair. Assist bar was properly attached to resident #1's bed and raised/lowered correctly. Functions of the bed were checked. The head and foot of the bed raised and lowered properly. The bed raised and lowered also with no issues. The mattress fit was checked and was correct. There was no physical damage noted to the exterior of the mattress (no rips, tears or sunken spots).
- Resident #1's incidents were reviewed for the last six months and all prior interventions were assessed and found to be in place.
- Staff in-service for CNAs: Reporting any incident or accidents that occur with a resident. If unsure if something is new or if you should report, always report to the nurse or supervisor. If you feel like an additional assessment may need to be done then report to a management nurse.
- Staff in-service for nurses: An incident report should be done for any of the following (bruises, skin tears, falls, unintentional change in plane, setting a resident in the floor from getting weak, sliding out of bed or wheelchair, etc). Physician, responsible party, and DON should all be made aware. Proper documentation should be done and include any new orders or treatment. If any immediate actions should be put into place, then make sure those are done (increase supervision, increase monitoring, etc.).
- Staff in-service: Abuse & Neglect, reporting any change in condition or change in status to nurse/nurses station.
- QA initiated to ensure nurse competency and return demonstration for incident/accident reporting and completion of appropriate documentation.
- Resident #1 returned to the facility with orders for non-weight bearing status and hip rehab exercises. He is a two person assist with lift transfer. Nursing assessment completed.
- As an immediate protective action, S6CNA sat near the resident's door providing additional supervision due to him having had a fall and behaviors.
Failure to Document Meal Intake for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not document the supper meal intake percentages daily for a resident who had severe cognitive impairment and required assistance with activities of daily living. The resident had multiple diagnoses, including hypertension, diabetes mellitus, and dementia, and was at risk for weight loss due to leaving 25% or more of food uneaten at most meals. Despite an intervention in the care plan to document the resident's food intake with each meal, there was no documented evidence of the supper meal intake percentage for July and August 2024. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Document Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated competency in administering insulin injections, as evidenced by the lack of documentation of injection sites for a resident with multiple health conditions, including diabetes mellitus. The medical record review for the resident revealed an admission with several diagnoses, such as hypertension, diabetes, and severe cognitive impairment, requiring assistance with daily activities. The care plan indicated the need for regular blood sugar monitoring and insulin administration according to a sliding scale. However, the Medication Administration Record (MAR) showed no documented evidence of the sites of administration for sliding scale insulin injections 47 times in July and 6 times in August. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to document the injection sites, highlighting a lapse in the nursing staff's competency in managing the resident's diabetes care.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by a Certified Nurses Assistant (CNA) while providing care to a resident on Enhanced Barrier Precautions (EBP). The resident, who had a history of multiple health issues including MRSA in the urine, was placed on EBP to prevent the spread of multi-drug resistant organisms. Despite the presence of a sign indicating the need for PPE, the CNA did not wear a gown and gloves as required during high-contact care activities. During the observation, the CNA was seen performing incontinent care without wearing any PPE initially and later donned gloves without washing hands. The CNA proceeded to perform various tasks, including transferring the resident and providing hygiene care, without changing gloves or washing hands between tasks. This included touching the resident, handling personal items, and moving equipment, all with the same pair of gloves, which were also used to clean the resident. The CNA's actions were confirmed to be against the facility's EBP policy, which mandates the use of gloves and gowns during high-contact activities and changing PPE before caring for another resident. The Infection Control Nurse confirmed the breach in protocol, acknowledging that the CNA should have adhered to the EBP requirements, including proper hand hygiene and PPE use. Additionally, the wipes used during care were improperly handled, as they were taken into the resident's room and later placed back on the hall cart for potential use on another resident.
Resident Injury Due to Improper Use of Lift Chair
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident during a whirlpool bath. The resident, who had moderate cognitive impairment and was at high risk for falls, was not properly secured with a seat belt in a lift chair. This resulted in the resident falling from the chair to the floor, sustaining severe injuries including a fractured skull, fractured left arm, a laceration to the head, and a brain bleed. The incident occurred when a Certified Nurse Aid (CNA) assisting the resident failed to secure the seat belt on the lift chair. While the CNA was looking down to lock the lift's wheels, the resident fell from the chair. The resident was found unresponsive on the floor with shallow respirations and a slow heart rate. Immediate medical attention was provided, and the resident was taken to the emergency room for further treatment. Interviews and facility records revealed that the CNA did not follow the facility's policy, which required securing the safety belts when using the lift system. The CNA was suspended during the investigation, and it was confirmed that the failure to use the seat belt directly led to the resident's fall and subsequent injuries.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed at risk for elopement, resulting in the resident eloping from the facility. The resident, who had severe cognitive impairment and was identified as an elopement risk, was found approximately 300 yards outside the facility by a staff member. The incident occurred on 04/19/2024 at approximately 6:20 p.m., and the resident was returned to the facility at approximately 6:32 p.m. The resident's medical record indicated diagnoses including depressive disorder, macular degeneration, dementia, and hypothyroidism, and the resident had a history of expressing a desire to go home, which was noted as a risk factor for elopement. The facility's investigation revealed that the resident exited the building through an exit door by the activity room. The resident was able to ambulate independently and was observed walking in the hallways by multiple staff members. Interviews with staff confirmed that the resident frequently walked independently in the halls. The facility's camera footage showed the resident exiting the building at 6:20 p.m. on 04/19/2024. The resident was found by an employee and brought back to the facility, with no apparent injuries noted upon a body audit. The facility's policies and procedures for monitoring residents at risk for elopement were not adequately followed, as evidenced by the resident's ability to exit the building without staff intervention. The care plan for the resident included interventions such as monitoring for risk factors, encouraging participation in activities, and educating staff on the resident's potential for elopement. However, these measures were insufficient to prevent the resident from eloping, leading to the Immediate Jeopardy situation on 04/19/2024.
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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.
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Nursing homes near Oak Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carroll Health And Rehab Llc | 0.6 mi | — | 0 | 0 |
| Cypress At Lake Providence | 12.7 mi | — | 1 | 0 |
| Oak Woods Home For The Elderly | 25.3 mi | — | 0 | 0 |
| Deerfield Nursing And Rehabilitation Center | 28.7 mi | — | 4 | 1 |
| Sharkey-issaquena Nursing Home | 29.3 mi | — | 0 | 0 |
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