Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Point Care Center Inc during CMS and state inspections, most recent first.
A resident with a Foley catheter and a stage 3 coccyx pressure ulcer was not placed on EBP, and the room lacked an EBP sign. Staff provided wound care, transfers, and catheter care without consistently wearing gowns, and CNAs handled the catheter bag and lift equipment without the required PPE. Staff interviews showed inconsistent understanding of EBP requirements, while the DON stated the resident had been missed for EBP.
A resident with intact cognition but hemiplegia, decreased mobility, and frequent bladder incontinence was care planned as dependent for toileting and peri-care with each incontinent episode, and facility policy required q2h rounding with incontinence checks. Over the course of an evening and night shift, CNAs and RNs observed the resident in a recliner multiple times but did not physically check the incontinence brief, relying instead on visual checks and the resident’s call light. One CNA was told by the resident to leave the room and later provided a urinal around 4 a.m. but did not return to empty it, did not physically assess for incontinence, and did not notify the nurse or another CNA of the resident’s refusal of care. By morning rounds, two CNAs found the resident in the previous day’s clothing with his pull-up brief, clothing, incontinence pad, and recliner saturated with urine, and noted a strong urine odor, confirming that incontinence checks and changes had not been performed for an extended period.
A resident with severe cognitive impairment sustained burns from a hot liquid due to inadequate supervision during a shift change. The resident was left with a cup of coffee on her lap, resulting in blisters on her left abdomen and thigh. The incident revealed a lack of communication and proper handover between shifts, as well as the facility's failure to assess residents' ability to handle hot liquids safely.
The facility failed to address previously identified deficiencies, resulting in repeat citations for issues related to abuse reporting, investigation, and medication storage. Despite the QAPI Program's framework, the facility did not effectively implement or maintain corrective actions, leading to ongoing deficiencies.
The facility failed to conduct annual QAPI training for all staff in 2023, with the last training conducted in the fall of 2022. The Administrator admitted the oversight, and the Facility Assessment Tool for 2024 highlighted the necessity of such training.
The facility failed to notify the physician after a resident with severe cognitive impairment and a history of depression expressed thoughts of self-harm on two occasions. Despite the facility's policy requiring physician notification for significant changes in mental status, only the family was informed in one instance, and there was no documentation of physician notification.
The facility failed to update the Care Plan for a resident who started a diuretic medication. Despite severe cognitive impairment and multiple medical diagnoses, the Care Plan lacked documentation for the diuretic. Interviews revealed that diuretics were not typically included in Care Plans, and the facility's policy did not address this need.
A resident with hypertension and severe cognitive impairment had an elevated blood pressure reading of 190/88 accompanied by stomachache and back pain. The facility failed to recheck the blood pressure, notify the physician, and document a follow-up Progress Note, leading to a deficiency.
A medication cart was found unlocked and unattended on two separate occasions, with medication cards and a narcotic drawer accessible. The facility's policy requires all compartments containing drugs to be locked when not in use.
Failure to Use EBP During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were used during wound care and urinary catheter care for a resident with a urinary catheter and a stage 3 pressure ulcer on the coccyx. The resident’s MDS showed a BIMS score of 13 out of 15, indicating mild cognitive impairment, and listed diagnoses including diabetes, arthritis, and cancer. The resident was dependent on staff for toileting, lower body dressing, and transfers. Clinical physician orders included wound care to the coccyx and an indwelling Foley catheter, but there was no order for EBP during wound care or catheter care. During observation, the resident’s room did not have a sign indicating the need for EBP. Staff provided wound care while leaning over the resident, repositioning him, and handling the wound without first donning a gown. Staff also completed catheter-related care without wearing a gown. During another observation, two CNAs transferred the resident from a wheelchair to bed and handled the catheter bag without donning gloves or a gown. One CNA then emptied the catheter bag and cleaned the catheter port after hand hygiene and gloving, but still without a gown. Staff interviews reflected differing understanding of when EBP should be used, with some stating it applied to residents with wounds or catheters and others stating gloves alone were needed for wound or catheter care. The DON stated the resident had been missed for EBP and that staff should have been wearing a gown when providing care. Facility policy stated signs should be posted for residents on EBP and that staff entering for hands-on care must wear gloves and an isolation gown, with additional PPE for catheter care. Another policy stated residents with wounds or indwelling devices such as urinary catheters should use PPE during high-contact care activities, device care, and wound care.
Failure to Perform Timely Incontinence Checks and Care Over Night Shift
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence checks and care for a resident who was dependent on staff for toileting hygiene and had a history of bladder incontinence. The resident’s MDS showed intact cognition (BIMS 14/15), hemiplegia following a CVA affecting one upper and lower extremity, decreased mobility, and frequent bladder incontinence. The care plan identified the need for assistance with ADLs related to stroke-related weakness and balance/gait impairment, and specified that the resident required assistance of one staff member for toileting and that the peri-area should be cleaned with each incontinent episode. Facility policy required rounding on all residents approximately every two hours and at the end of each shift, including incontinence checks and peri-care or toileting as necessary. On the evening and night in question, documentation and interviews showed that the resident was last documented as continent at approximately 3:10 PM after toileting. Around 6:30 PM, a CNA (Staff B) informed another CNA (Staff A) that both residents in the room were ready for bed. At approximately 6:38 PM, the resident used the call light to request assistance, and Staff A assisted him to his recliner per his request; during this interaction, the resident told Staff A to leave the room using profanity. Staff A then assisted the roommate before exiting. Later, at about 9:15 PM, an RN (Staff C) administered medications and asked if the resident was ready for bed; the resident declined. At 10:00 PM and again at 12:00 AM and 2:00 AM, another CNA (Staff D) reported only observing the resident in his recliner during rounds, without physically checking his incontinence brief. The POC entries at 12:33 AM and 2:33 AM showed no void documented at those times. Around 4:00 AM, the call light report showed the resident requested assistance. Staff A stated that at this time the resident requested to go to bed, but Staff A convinced him to remain in the recliner because of the time, and instead provided a urinal. Staff A acknowledged he did not return to empty the urinal or physically check the resident’s brief, relying on the resident to use the call light if he needed changing. Staff A also did not inform the nurse or other aides that the resident had previously told him to leave the room. At approximately 6:20 AM, the POC showed the resident was incontinent, and between about 6:30 and 6:45 AM, two CNAs (Staff F and Staff G) assisted the resident up for the day and found his clothes, incontinence pad (chuck), and recliner soaked with urine, and noted he was still wearing the previous day’s clothes. Staff F reported that the resident was wearing a pull-up brief, which he could not manage independently due to hemiplegia, and that the recliner was saturated from top to bottom. Staff F and Staff G both reported a strong urine odor and confirmed that no one else had come in to toilet or change the resident during the night, and that staff had not been physically checking his brief, instead relying on visual checks and the resident’s call light use. The DON stated that the resident being upset was not a reason to avoid attempting physical check and changes, and that the CNA should have reported the resident’s refusal of care so that others could intervene.
Resident Burned by Hot Liquid Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure a resident with severely impaired cognition remained free from burns from hot liquid. The incident occurred when the resident was found with a cup on their lap during a shift change to the night shift, resulting in blisters to the left abdomen and thigh and documented pain. The resident, who had a history of cerebrovascular accident (CVA) with right-sided weakness and severe cognitive impairment, required supervision for eating and was known to spill liquids on herself. Despite this, the resident was left unsupervised with a hot liquid, leading to the injury. The incident report and clinical records revealed that the resident was found by a CNA with a cup on her lap and blisters on her left abdomen and thigh. The resident was unable to communicate what had happened due to her cognitive impairment. The CNA and nurse on duty at the time of the incident did not adequately supervise the resident, and the resident was left with a supper tray in her room, which included a cup of coffee. The resident's care plan indicated that she should not be given hot liquids without supervision, but this was not followed. Interviews with staff indicated that there was a lack of communication and proper handover between shifts. The staffing CNA, who was unfamiliar with the facility and the resident's needs, did not provide adequate supervision. Additionally, the facility had not previously assessed residents for their ability to handle hot liquids safely. This lack of assessment and supervision led to the resident sustaining burns from the hot liquid, highlighting a significant deficiency in the facility's care practices.
Repeat Deficiencies in Abuse Reporting and Medication Storage
Penalty
Summary
The facility failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current Recertification and Complaint Survey. The deficiencies included issues related to freedom from abuse, timely reporting of alleged abuse, investigating, preventing, and correcting alleged abuse, and proper storage of medications. These deficiencies were previously identified during surveys completed in the last seventeen months, indicating a lack of sustained compliance and effective corrective actions by the facility. During an interview, the Administrator acknowledged the expectation of not repeating the same citations and mentioned plans to meet with the DON and Department Heads to address the issues. The facility's QAPI Program, reviewed in January 2023, outlined the need for a comprehensive, data-driven approach to quality monitoring and improvement. However, the repeated citations suggest that the facility's QAPI process was not effectively implemented or maintained, leading to ongoing deficiencies in critical areas of resident care and safety.
Failure to Conduct Annual QAPI Training for Staff
Penalty
Summary
The facility failed to conduct annual training on Quality Assurance and Performance Improvement (QAPI) for all staff in 2023. The training competencies for 2023 lacked documentation for staff completing QAPI training. During an interview, the Administrator admitted that the training was not scheduled and should have been completed in December of the previous year. The last QAPI training was conducted in the fall of 2022. The Facility Assessment Tool for 2024 indicated the necessity of QAPI fundamentals and team involvement training, and the facility's QAPI policy required mandatory education and skills training, which were not fulfilled.
Failure to Notify Physician of Resident's Self-Harm Thoughts
Penalty
Summary
The facility failed to notify the physician after a resident expressed thoughts of self-harm on two separate occasions. The resident, who had severe cognitive impairment and a history of depression and dementia, made statements indicating a desire to die with her children and later mentioned wanting to shoot herself. Despite these alarming comments, there was no documentation that the physician was notified, although the family was informed in one instance. Interviews with staff revealed inconsistencies in their responses to the resident's expressions of self-harm. Some staff members believed they had notified the physician, while others confirmed that only the family was contacted. The facility's policy requires notifying the physician of significant changes in a resident's mental or psychosocial status, but this protocol was not followed in these instances. The lack of documentation and adherence to policy contributed to the deficiency identified in the report.
Failure to Update Care Plan for Diuretic Medication
Penalty
Summary
The facility failed to update the Care Plan for a resident who started a diuretic medication. Resident #19, who has severe cognitive impairment as indicated by a BIMS score of 5 out of 15, was prescribed Bumetanide for heart failure and chronic kidney disease. Despite the new medication order, the Care Plan lacked documentation for a Focus Area and interventions related to the diuretic medication. This oversight was identified through clinical record review, observations, and staff interviews. During interviews, both the Assistant Director of Nursing (ADON) and the Interim Director of Nursing (DON) acknowledged that diuretics were not typically included in the Care Plans. The facility's undated MDS/Care Plan Review Policy did not address the need for medications like diuretics to be documented in the Care Plan. This gap in policy and practice led to the deficiency, as the Care Plan did not reflect the resident's current medical treatment and needs.
Failure to Follow Protocol for Elevated Blood Pressure
Penalty
Summary
The facility failed to recheck a blood pressure, notify the doctor, and document a follow-up Progress Note after an elevated blood pressure reading of 190/88 with a stomachache and back pain for Resident #30. The resident had a diagnosis of hypertension and non-Alzheimer's dementia, with a severely impaired cognition score of 4 out of 15 on the Brief Interview for Mental Status (BIMS) exam. The initial elevated blood pressure reading was documented, but there was no follow-up recheck, no notification to the physician, and no additional Progress Note to document the resident's symptoms or the effectiveness of the administered Tylenol for pain relief. Interviews with staff revealed inconsistencies in the handling of the elevated blood pressure. Staff F, an RN, stated she would recheck the blood pressure and notify the provider if it remained elevated, but there was no documentation to support this. Staff T, another RN, could not recall the elevated blood pressure reading and stated she would normally document a recheck if performed. The Assistant Director of Nursing (ADON) and the Interim Director of Nursing (DON) both confirmed that the expected protocol was to recheck the blood pressure, document the findings, and notify the physician if the elevated reading persisted. The facility's policies on vital parameters and change of condition notifications were not followed in this instance, leading to the deficiency.
Medication Cart Left Unlocked When Unattended
Penalty
Summary
The facility failed to ensure a medication cart remained locked when staff were not present. On two separate observations, a medication cart was found unlocked outside a resident's room, with medication cards inside the cart. The first observation occurred at 10:45 AM, where the cart was unlocked and the drawer could be opened without a key. The second observation at 11:14 AM revealed the main lock of the cart was depressed, but the second drawer on the right side was unlocked and slightly open, with a medication card visible inside. Staff were not present during either observation. When queried, an LPN confirmed that the unlocked drawer was the narcotic drawer and questioned how the main lock could be engaged while the drawer remained unlocked. The Interim DON stated that medication carts should be locked anytime nursing staff are not actively using them. The facility's policy on the storage of medication, revised in April 2007, mandates that compartments containing drugs and biologicals must be locked when not in use and that carts should not be left unattended if open or potentially accessible to others.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birkwood Village Of Fort Madison | 8.1 mi | ★★★★★ | 6 | 0 |
| Aspire Of Donnellson | 8.1 mi | — | 0 | 0 |
| Montrose Health Center | 13.6 mi | ★★★★★ | 4 | 0 |
| New London Specialty Care | 14.2 mi | ★★★★★ | 6 | 0 |
| Oakview Nursing And Rehabilitation | 15.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.