West Point Community Living Center

In the surveyor’s words

From the most serious findings on record at West Point Community Living Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 7, 2025

  Based 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. […]

• Actual harm, isolatedF610Aug 7, 2025

  Based 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. […]

• Actual harm, isolatedF657Mar 23, 2023

  Based on staff interview, record review, and facility policy review, the facility failed to update and revise a care plan with the appropriate ordered wound care for one (1) of three (3) resident care plans reviewed. Resident #1 Findings include: Record review of facility policy titled, Care Plan - Comprehensive, revealed, It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. The policy also revealed, 2 The comprehensive care plan had been designed to: .d. Reflect treatment goals and objectives in measurable outcomes that incorporate the resident's personal and cultural preferences and wishes. […]

• Actual harm, isolatedF684Mar 23, 2023

  Based on staff interviews, observations, record review, and facility policy review, the facility failed to promote healing of a wound and to prevent the worsening of a wound as evidenced by the physician's ordered treatment not being followed for one (1) of three (3) residents with skin issues reviewed. Resident #1 Findings include: Review of the facility policy titled, Skin Care Process, dated 1/17/18, revealed, It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur. […]

• No harm, potential for more than minimal, patternF880Aug 7, 2025

  Based 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. […]