Inspection Reports for
West Point Care Center

The complaint investigation was substantiated. Resident #1 was found neglected in terms of incontinence care, with staff failing to perform physical checks and changes despite call light use and observable soiling. Staff A was kicked out of Resident #1's room and did not report this to nursing staff, contributing to the neglect.

The facility failed to perform timely checks and changes for Resident #1's incontinence care over an 8-hour period. Staff interviews and record reviews revealed inadequate monitoring and delayed response to Resident #1's needs, resulting in the resident being found soaked with urine and wearing soiled clothing.

The visit included investigation of complaint #128279-C.

The facility was found deficient in updating comprehensive care plans for residents at risk of elopement and antibiotic use, failure to meet professional standards in medication administration, and failure to ensure accident hazards were minimized. Specific deficiencies included incomplete care plans for residents #18 and #26, improper inhaler administration for resident #16, and inconsistent implementation of fall prevention interventions for resident #18.

The facility failed to update care plans for two residents regarding elopement risk and antibiotic use, failed to instruct a resident to swish and spit after inhaler use, and did not consistently implement fall interventions for one resident. The facility reported a census of 27 residents.

The complaint investigation found that Resident #5 did not receive showers as ordered, with multiple refusals not properly documented or communicated to nursing staff. Staff disciplinary action was taken due to carelessness and failure to follow protocols. The facility acknowledged the issue and implemented corrective measures.

The facility failed to provide daily showers per physician orders for Resident #5, who required substantial assistance. Documentation was lacking regarding nurse notification of shower refusals, and staff inconsistently followed protocols for reporting refusals.

Complaint #118918-C was substantiated based on findings related to inadequate ADL care and shower provision.

The facility failed to provide daily showers per physician orders for 3 of 3 residents reviewed, including Resident #5, who refused some showers. The facility lacked documentation of nurse notification of refusals. Complaint #118918-C was substantiated.

The complaint investigation was substantiated with findings that Staff B verbally abused residents, including those with dementia and cognitive impairments. The facility failed to report the abuse timely and did not conduct a thorough investigation. Multiple staff statements and resident reactions supported the allegations.

The facility failed to protect residents from verbal and mental abuse by a Certified Nursing Assistant (Staff B), who was reported to have made degrading and humiliating comments to residents, especially those with cognitive impairments. The facility also failed to timely report the abuse allegations to the State Agency and did not conduct a thorough investigation into the allegations.

The investigation was complaint-driven, involving allegations of failure to notify physician of self-harm thoughts, verbal and mental abuse by staff, failure to report abuse timely, failure to investigate abuse allegations, failure to update care plans, failure to follow up on elevated blood pressure, medication cart security issues, and resident burn injury from hot liquid. Substantiation status is not explicitly stated.

The facility failed to notify the physician of a resident's self-harm thoughts, protect residents from verbal and mental abuse by a staff member, timely report suspected abuse, conduct thorough investigations of abuse allegations, update care plans for new medications, recheck and document elevated blood pressure, secure medication carts, and prevent a resident burn injury from hot liquid. Multiple residents were affected, and an Immediate Jeopardy was identified and later removed after corrective actions.

Complaint #114806-C was substantiated. Facility Self-Reported Incident #116131-I was substantiated.

The facility was found to have deficiencies related to failure to notify the physician of significant resident changes, failure to protect residents from verbal abuse and neglect by staff, failure to report alleged violations timely, failure to update care plans, failure to ensure medication cart security, and failure to provide adequate staff training and supervision. The complaint and self-reported incidents were substantiated.

The facility failed to ensure Resident #5's medical needs were met according to professional standards, including missed medical appointments and inadequate follow-up on declining health conditions. The report highlights failures in coordinating transportation and communication with healthcare providers, which contributed to Resident #5's hospitalization for sepsis.

The visit was complaint-related, investigating Complaints #107104-C, #108352-C and Facility Reported Incidents #107940-I and #111320-I. Complaint #108352-C was substantiated.

The facility failed to ensure that Resident #5's medical needs were met according to professional standards of care, specifically regarding coordination and follow-up of urology appointments and transportation, which contributed to the resident's decline and hospitalization for sepsis.

Complaint #104069-C was not substantiated. Facility-reported incidents #98965-I and #106858-I were substantiated.

The facility was found deficient in multiple areas including failure to ensure advance directives were properly completed and signed, failure to prevent staff-to-resident abuse, failure to develop and implement abuse prevention policies and training, failure to report abuse allegations timely, failure to thoroughly investigate abuse allegations, failure to develop a comprehensive care plan for respiratory therapy, failure to provide proper respiratory care including CPAP equipment cleaning, failure to properly label and store medications, failure to update the facility-wide assessment annually, and failure to ensure all staff received abuse prevention training.

The facility failed to implement an ongoing system of surveillance to identify possible trends of communicable diseases, specifically lacking timely infection tracking and trending for November 2020. This deficiency had the potential to affect all 25 residents. The facility was found not in compliance with infection prevention and control requirements.

Facility reported incident #92672 was substantiated involving inadequate supervision leading to elopement of Resident #1.

The facility failed to adequately supervise a cognitively impaired resident who eloped from the facility without staff knowledge. The resident was found approximately 10 miles away at her home. The facility identified 4 residents as independently mobile and cognitively impaired. Additionally, the facility failed to complete annual performance reviews for nurse aides as required.