West Point Community Living Center

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure residents right to be free from abuse for six (6) of 6 residents reviewed for abuse and neglect. Resident #20, #21, #5, #41, #34 and #50. On 06/30/25 the facility reported that a resident with a history of behaviors and aggression towards others, (Resident #65) stood up from his chair while sitting in the dining room, and had gotten behind Resident #20 while he sat in his wheelchair and choked him. Staff heard other residents yelling for help and the staff separated Resident #65 from choking Resident #20. Resident #20 immediately began to have seizures that lasted for three or more minutes and continued to have multiple seizures a day until he was sent out to the hospital on [DATE]. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to investigate a resident's allegation of sexual abuse by another resident for one (1) of six (6) residents reviewed for abuse. The facilities failure to investigate and implement protective interventions made the resident feel angry, violated, and unsafe, and lead him to avoid leaving his room for fear of being watched by the alleged perpetrator. This failure placed Resident #34 at risk for further abuse, emotional distress, and significant harm to his sense of safety and well-being. Resident #34Findings Include:Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of 10/22 revealed under, 8. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection during medication administration as evidenced by failing to ensure Enhanced Barrier Precautions (EBP) were utilized and ensuring a multi-use glucometer was properly cleaned and disinfected for two (2) of four (4) medication observations. Resident #21, Resident #40Findings include:Record review of the facility policy titled, Enhanced Barrier Precautions with no revision date revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . g. device care or use (.feeding tube) . [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to follow the requirements for obtaining a Preadmission Screen (PAS) for a resident in the facility for greater than 30 days for one (1) of five (5) residents reviewed. Resident #10Findings include: Record review of facility policy titled, admission Criteria, dated 4/10/23, revealed, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process . During an interview on 8/6/25 at 8:20 AM, the Social Worker stated Resident #10 was admitted to the facility for therapy with plans to be discharged home within 30 days, but her therapy was extended. She acknowledged the resident had diagnoses of bipolar disorder and anxiety disorder. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for a resident with a diagnosis of post-traumatic stress disorder (PTSD) (Resident #5), Bipolar and anxiety disorder (Resident #10), and failed to implement a care plan for a resident receiving nectar thickened liquids (Resident #27) for three (3) of 22 care plans reviewed. Resident #5, #10, #27Findings Include: Resident #5 Review of the facility policy titled “Care Plans, Comprehensive Person-Centered” reviewed 10/2022, revealed under, “Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident . [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to assess and identify potential triggers for a trauma survivor for one (1) of three (3) residents reviewed for post-traumatic stress disorder (PTSD). Resident #5Findings Include:Review of the facility policy titled Trauma-Informed and Culturally Competent Care, revised 8/22, revealed under Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice, and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. An observation and interview with Resident #5 on 8/4/25 at 10:52 AM revealed he was lying in bed with the curtains closed and the room dark. The resident stated he suffered from depression and took an antidepressant. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to maintain a medication error rate of less than 5% by ensuring that residents received all physician-ordered medications for three (3) of 28 medication administration opportunities observed during medication pass. The medication error rate was 10.71%.Review of the facility policy titled, Medication Administration dated November 1, 2008 revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . B. Administration . 2) Medications are administered in accordance with written orders of the attending physician . On 8/06/2025 at 9:35 AM, a medication administration observation with Registered Nurse (RN) #1 revealed a medication administration to Resident # 5. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to serve a therapeutic diet as ordered for one (1) of six (6) residents reviewed for the dining task. Resident #27Findings Include:An interview with the Administrator on 8/7/25 at 10:06 AM revealed the facility did not have a policy regarding serving diets as ordered. An observation of Resident #27's lunch meal on 8/4/25 at 11:20 AM revealed she received a meal in the dining room consisting of cornbread dressing with cranberry sauce, rice with gravy, diced carrots, a roll, milk, and apple cobbler. The resident was provided with a carton of 2% milk (non-thickened) with a straw inserted. She was observed feeding herself. A record review of Resident #27's meal ticket revealed the following note: Nectar liquids, nectar milk. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from misappropriation of a resident's medication for one (1) of five (5) residents reviewed for misappropriation.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to prevent further potential medication misappropriation by allowing a nurse to continue to work during an investigation for one (1) of five (5) residents reviewed for misappropriation of property.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to report an allegation of abuse timely for one (1) of three (3) residents reviewed. Resident #1. Based on the implementation of the facility's corrective actions taken on 11/08/2024, the deficient practice was determined to be Past Non-Compliance, and the facility had put measures in place to correct the deficient practice prior to the State Agency's (SA) entrance into the facility on [DATE]. Findings Include: Record review of the facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Education with revision date of 11/14/17 revealed Reports must be within 24 hours (if the allegation does not involve abuse or there is not serious bodily injury) after forming your reasonable suspicion. [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review the facility failed to ensure that a resident was free from a significant medication error as evidenced by one drop of mometasone furoate external scalp solution being instilled into a resident's left eye in place of the physician ordered eye drops for one (1) of three (3) residents reviewed. Resident #2. Findings Include: Record review of the facility policy titled Adverse Consequences and Medication Errors with reviewed date of 08/2023 revealed under Medication Errors, 1. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: d. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review the facility failed to ensure a medication was properly stored as evidenced by a tube of Hydrocortisone Topical Cream being left on a resident's overbed table for one (1) of three (3) residents reviewed. Resident #2. Findings Include: Record review of the facility policy titled Medication Storage in the Facility dated December, 2006, revealed under Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to prevent the spread of infection as evidenced by placement of a treatment cart inside a resident room during treatment care for one (1) of three (3) survey days.

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to notify the resident/resident representative and failed to notify the Ombudsman of transfers to the hospital in writing of a transfer/discharge for one (3) of three (3) residents reviewed. Residents #17, #33, and #56.

Inspectors wroteBased on staff interviews and record review the facility failed to ensure that a stop date was ordered for an as needed (PRN) psychotropic medication for one (1) of five (5) residents reviewed for medications. Resident #33.