West Village Post Acute

Inspectors wroteBased on observation and interview, the facility failed to ensure beverages were served in a safe and sanitary manner to residents who ate in their rooms. This deficient practice had the potential to affect all residents who received beverages from the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow the planned menu. Specifically, the facility served the incorrect portion size for the pureed diets for the lunch meal on 01/13/26. This failure had the potential to affect 13 residents who received pureed diets.

Inspectors wroteBased on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident (R)81) of 2 residents reviewed for pressure ulcers. Specifically, R81's Quarterly MDS, with an Assessment Reference Date (ARD) of 12/09/25, did not reflect that the resident had intravenous (IV) access, specifically a peripherally inserted central catheter (PICC).

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was in place to address the care needs associated with the use of a peripherally inserted central catheter (PICC) line for 1 (Resident (R)81) of 2 sampled residents reviewed for pressure ulcers. Specifically, the facility resolved a care plan addressing R81's PICC line on 12/04/25 and one was never re-initiated, despite ongoing PICC line use and access.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide Resident (R)45 with an ordered oral nutritional supplement and failed to serve the correct portion size to the resident during the lunch meal on 01/13/26. This deficient practice affected 1 of 5 sampled residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide care and treatment according to professional standards for peripherally inserted central catheter (PICC) lines (long thin flexible tube inserted through a peripheral vein in the upper arm and advanced to the large vein near the heart) for 1 (Resident (R)81) of 2 residents reviewed for PICC lines. Specifically, the facility failed to ensure R81's PICC line dressing was secure and changed per physician order and facility policy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff used the proper personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBPs) for 1 (Resident (R)81) of 2 residents reviewed for infection control.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to report an allegation of abuse to the state survey agency timely for 1 (Resident #1) of 3 residents reviewed for abuse/neglect.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to ensure resident rights were upheld related to voting in the Presidential Election, for 8 of 8 residents reviewed for Resident Rights.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure Resident (R)79's Protected Health Information (PHI) was maintained in a private manner, for 1 of 9 residents observed during medication administration.

Inspectors wroteBased on review of facility policy, observation, and interviews, the facility failed to remove expired medication cards in 1 of 6 medication carts reviewed.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure 1 Resident (R)59 of 8 residents reviewed for abuse was free from abuse. This deficient practice resulted in physical harm to R59 when R274 entered R59's room, while the resident was in bed, and punched her in the face. R59 sustained fractures of the zygomatic arch (cheekbone) and orbital area (eye socket).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and hygiene and food handling standards were followed to prevent the potential spread of foodborne illness to 115 of 123 total residents (eight residents received nutrition via feeding tubes). Specifically, concerns were noted with the dishwasher water temperatures, hand hygiene when touching ready to eat foods, cleanliness of kitchen surfaces, labeling and dating of foods, wearing hair coverings, cross contamination when handwashing, and food storage.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure palatable food was served to 5 of 64 sampled residents (Resident (R)1, R81, R102, R66, and R76). Residents complained foods were not flavorful and were not hot when they received their meals.

Inspectors wroteBased on review of facility policy, record review, obsevations, and interview, the facility failed to ensure residents received care and services in a dignified manner for 1 of 2 residents reviewed for dignity (Resident (R) 119). Staff entered R119's room on two occasions and turned off his call light without addressing R119 or attempting to determine what he needed.

Inspectors wroteBased on review of facility policy, observations, record review, and interview, the facility failed to ensure 1 of 1 resident (Resident (R) 82) had their call light within reach.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to ensure residents were allowed to have visitors of their choosing for 1 of 1 Resident (R)121 reviewed for visitation. R121 was not allowed visits from his responsible party.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to act upon a grievance for 1 of 2 Residents (R)6 reviewed for personal property.

Inspectors wroteBased on review of the facility policy, record review, observation, and interviews, the facility failed to ensure the right to be free from restraints was exercised for 1 of 1 Resident (R)175 reviewed for restraints. Specifically, staff physically restrained (restrict freedom of movement) of R175 when she was placed in a geri-chair. The facility's deficient practice had potential to inflict mental anguish and/or physical harm to R175.

Inspectors wroteBased on review of the policy review, record review, observations, and interviews, the facility failed to provide a program of ongoing activities for 1 of 3 Residents (R)121 reviewed for activities.

Inspectors wroteBased on review of the facility policy, record review, observation, and interviews, the facility failed to ensure 3 Residents (R)91, R118, and R120 had therapy ordered splints applied to prevent the development of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent weight loss for 1 of 4 residents reviewed for nutrition (Resident (R) 60). The facility failed to ensure R60 was provided with physician ordered built up utensils and nursing staff assist the resident at mealtimes. R60 had a 7.72% weight loss from 09/05/22 to 10/13/22.

Inspectors wroteBased on policy review, review of Centers for Disease Control and Prevention (CDC) guidelines, and interview, the facility failed to revise their pneumococcal vaccine policy to current pneumococcal vaccination guidelines. This failure increased the risk for residents not vaccinated per guidelines to contract pneumonia. The facility also failed to offer one (Resident (R) 107) out of a survey sample of five reviewed for pneumococcal vaccination, who received the PPSV [Pneumococcal Polysaccharide Vaccine] 23, but there was no evidence the resident received the PCV13 [Pneumococcal conjugate vaccine] prior to the updated guidance from the CDC for pneumococcal vaccinations.