West Point Community Living Center

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. device care or use (.feeding tube) . Record review of the facility policy titled, Blood Sampling-Capillary (Finger Sticks) undated, revealed Purpose: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. She confirmed the Pre-admission Screening (PAS) process evaluated residents for proper placement in nursing facilities and she confirmed the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 . Record review of Resident #5’s Care Plans revealed a care plan was not developed for past traumatic events or potential triggers. On 8/4/25 at 10:52 AM, an observation and interview with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. He explained that he served in the [NAME] Corps for 17 years and was diagnosed with post-traumatic stress disorder (PTSD). He stated that having to kill people during his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The medications administered were Diazepam tablet 5 mg (milligrams), Linzess oral capsule 145 mcg (micrograms) Prednisone tablet 5 mg (3 tablets) Pantoprazole…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.An observation of Dietary Staff #1 on 8/4/25 at 11:28 AM revealed she brought a carton of nectar-thickened milk to Resident #27's meal tray and removed the regular consistency milk. In an interview, Dietary Staff #1 confirmed that the resident had been served regular milk. She explained she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Resident #1 Cross Reference F610 Findings include: Record review of facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Education dated [DATE], revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals. Misappropriation of resident property - Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Record review of facility policy titled, Resident Rights dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Resident #1 Cross Reference F602 Findings include: Record review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 10/22, revealed, All reports of .theft/misappropriation of resident property are .thoroughly investigated by facility management. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . Record review of facility policy titled, Controlled Substances, undated, revealed, . 5. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 6. All keys to controlled substance containers are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Within 2 (two) hours (if the allegation involves abuse or there is serious bodily injury) after forming your reasonable suspicion In an interview on 02/03/25 at 9:40 AM, with the Administrator (ADM) she revealed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Wrong route of administration (e.g., ear drops given in the eye). On 03/20/24 at 9:00 AM, an interview with Administrator (ADM), revealed that on 02/25/24, Licensed Practical Nurse (LPN) #1 worked on the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. An observation and interview on 03/20/24 at 10:50 AM, with Resident #2 revealed her lying in her bed with her head raised at 90-degree angle and she was on her phone. Resident #2's bedside table was within reach positioned over her legs and there was a tube of prescription steroid cream sitting on her bedside table. The tube was inside a prescription…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review of facility policy titled, Standard Precautions dated May 30, 2012, revealed, Standard Precautions will be used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, membranes may contain transmissible infectious agents . Record review of facility policy titled, Infection Control Program dated February 1, 2008, revealed, The facility will establish and maintain an Infection Control Program focused on preventing the transmission of infectious disease in the long-term care setting. Purpose: Decrease the risk of infection for residents and staff; Monitor for the occurrence of infections and implement control measures; Identify and correct…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility policy titled Documentation RE: Transfer/Discharge, dated 9/18/2017, revealed It is the policy of this facility that when a resident is transferred or discharged his or her medical records be documented as to the reasons why such action was taken 5. Facility will notify the local ombudsman of the discharge and reason for discharge. Resident #33 An interview with Resident #33 on 6/20/2022 at 3:25 PM, revealed he had been in the hospital recently for pneumonia. An interview with the Social Worker (SW) on 6/22/22 at 8:22 AM, revealed she was unaware of the requirement to notify the ombudsman when a resident transfers to the hospital and this had not been done. She…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: An interview with the Director of Nursing (DON) on 6/22/22 at 3:00 PM, revealed the resident had an episode of yelling at staff in May. She revealed the Medical Provider was notified and an order for Ativan as needed (PRN) was given, but the resident calmed down and did not require any doses of the PRN medication. She confirmed the Ativan PRN medication, being a psychotropic medication, required a 14 day stop date, but a stop date was not given for the Ativan medication. An interview with the Administrator on 6/23/22 at 9:05 AM, revealed on 5/8/22, the resident was ordered Ativan PRN without a stop date. She confirmed psychotropic medications are to be used only when necessary and PRN use should be limited, and the facility failed to limit the PRN psychotropic medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.