Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Community Living Center during CMS and state inspections, most recent first.
Failure to Protect Residents from Resident-to-Resident Abuse: A resident with dementia, psychosis, and a documented pattern of aggression was not consistently supervised and repeatedly assaulted other residents, including choking one resident in a wheelchair until staff intervened and the victim began seizing. The same resident was also involved in other incidents of slapping, hitting, and fighting with residents over snacks and a walker, with staff and leadership acknowledging the behaviors were ongoing and that close monitoring had not been maintained.
Failure to investigate a resident's allegation of sexual abuse by another resident. A cognitively intact resident with MS reported sexually inappropriate comments and said he felt angry, violated, and unsafe, and avoided leaving his room because he feared being watched. The ADM confirmed she did not investigate the concern, and an RN acknowledged the report was resident-to-resident abuse but did not document or report it.
Failure to use EBP and properly disinfect a glucometer during resident care. An LPN administered PEG tube medications to a resident under EBP without wearing a gown, despite PPE being available at the door. In a separate event, an RN performed an Accu-Check on another resident, initially cleaned the multi-use glucometer with only an alcohol swab, then used bleach wipes but placed the device back on the cart without a clean barrier. Facility policy required gown and glove use for PEG tube care and cleaning/disinfecting reusable glucose meters between uses.
Failure to complete a PASARR screening led to the deficiency. A resident admitted for therapy stayed beyond the expected 30 days, and staff acknowledged the resident had bipolar disorder and anxiety disorder. The SW and Administrator confirmed the required PAS was not submitted even though the resident remained in the facility longer than planned. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness.
Failure to develop and follow comprehensive care plans for residents with mental health diagnoses and dysphagia. A resident with PTSD and bipolar disorder had no care plan for traumatic triggers or distressing situations, another resident with anxiety disorder and bipolar disorder lacked an individualized care plan for those diagnoses, and a resident ordered nectar-thick liquids was served regular milk instead of the prescribed consistency. Staff, including SS, the MDS nurse, and the DON/Administrator, confirmed the omissions and care plan failures.
Failure to assess and identify PTSD triggers for a resident with a trauma history. A cognitively intact veteran with PTSD, depression, nightmares, and sensitivity to crowds, noise, and loud environments was observed in a dark room with the curtains closed. Record review showed the resident’s PTSD diagnosis and prior suicidal behavior, but no trauma assessment had been completed. SS confirmed the assessment was not done to inform staff of his PTSD and potential triggers, despite the facility’s trauma-informed care policy.
Medication administration error rate exceeded the allowable threshold. During a med pass observation, an RN gave a resident nine ordered meds but omitted three physician-ordered meds at the scheduled time; the MAR later showed those meds documented as given shortly afterward. Record review and staff interview confirmed the omissions, and the interim DON stated nurses are expected to administer all ordered meds and notify the physician and DON if a med is unavailable. The resident had diagnoses including DM2, PTSD, schizoaffective disorder, bipolar type, and overactive bladder, and was cognitively intact with a BIMS of 15.
Therapeutic Diet Not Served as Ordered: A resident with dysphagia, dementia, and a history of aspiration pneumonia was served regular 2% milk with a straw even though the meal ticket and diet order specified nectar-thick liquids and nectar milk. Dietary staff later replaced the milk and confirmed the error, while the DON stated CNAs were expected to verify the meal ticket against the food served. The ST noted the resident remained on thickened liquids due to fluctuating condition and seizure episodes.
An LPN left medication keys unattended on two occasions, allowing a card of controlled pain medication prescribed to a resident with dementia and recent orthopedic surgery to go missing. The medication was not recovered, and the incident occurred despite the LPN's prior training on medication security policies.
A nurse was allowed to continue working and maintain access to the medication cart after narcotic medication was reported missing for a resident. Despite facility policy requiring removal from duty during such investigations, the LPN completed her shift and subsequent medication passes, and was not instructed to turn in her keys or leave the facility. Administration confirmed the nurse remained on duty throughout the investigation.
A resident with severe cognitive deficits was allegedly hit by a CNA in the dining room. An LPN witnessed the aftermath but failed to report the incident immediately, as required by facility policy. The incident was reported the following day, but the delay violated the policy, which mandates timely reporting of abuse allegations.
A resident with a history of Segmental and Somatic Dysfunction of the Cervical Region, Quadriplegia, and Morbid Obesity experienced a significant medication error when an LPN mistakenly instilled scalp solution into her eye instead of the prescribed eye drops. The resident reported burning, and the LPN contacted the Medical Director, who advised flushing the eye with saline. The resident continued to experience discomfort and sought further medical attention.
A facility failed to ensure proper storage of medication, leaving a tube of Hydrocortisone Topical Cream on a resident's overbed table. The resident, unable to self-administer due to physical limitations, had a history of keeping medications in her room against policy. Staff confirmed the resident was not evaluated for self-administration, and the medication should have been locked in the medication cart.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect when a resident with a history of dementia, psychosis, aggression, and physical altercations with other residents was not consistently monitored and was allowed to remain unsupervised with other residents. The report states that this resident had multiple prior incidents of hitting, slapping, cursing at, and grabbing residents and staff, and that one-on-one supervision had been used at times but was discontinued when behaviors improved. Staff interviews confirmed that the resident’s aggressive behavior was ongoing and that closer supervision would have prevented harm to other residents. On 06/30/25, the aggressive resident approached another resident in the dining room, came up behind him while he was seated in a wheelchair, and wrapped his arms around the resident’s neck in a choking manner. Staff and other residents yelled for help, and the two residents were separated. The resident who was choked had a history of seizures and immediately began having a seizure after the incident, with the report stating he had multiple seizures afterward and later required hospital evaluation. The resident reported that he felt frightened and stated, “He could have killed me.” Staff interviews confirmed the choking resident was not on one-on-one supervision at the time and that the facility had failed to adequately supervise him despite known aggressive behaviors. The report also describes additional resident-to-resident abuse involving the same aggressive resident. In one incident, he slapped another resident on the side of the head after an argument over snacks. In another, he slapped a resident in the face in the dining room, and in a separate event he struck a resident in the face and was involved in a physical tussle with another resident over a walker, resulting in injuries including swelling, bleeding, a cut above the eyebrow, and a later-confirmed hand fracture. Interviews with residents and staff described repeated verbal abuse, physical aggression, and fear among residents, while facility leaders acknowledged the resident’s behaviors were ongoing and that supervision had not been consistently maintained.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate a resident's allegation of sexual abuse by another resident and failed to implement protective interventions after the allegation was reported. Resident #34, who was admitted on 2/26/25 with a diagnosis of multiple sclerosis and had a BIMS score of 15 indicating intact cognition, reported that another male resident made sexually inappropriate statements to him, including asking him to perform sexual acts and stating he wanted to have sex with him. Resident #34 said the incident occurred in July near the 100 hall and that he reported it to the Administrator and RN #1. Resident #34 stated the incident made him angry, violated, and unsafe, and that he avoided leaving his room because he feared being watched by the other resident. He also stated he felt nothing would be done after he reported it to the Administrator and later contacted the Long-Term Care Ombudsman, who came to speak with him. During the interview, Resident #34 identified the other resident as Resident #45 and stated that Resident #45 had continued to watch him, which made him uncomfortable. The Administrator confirmed Resident #34 reported the incident but stated she did not investigate or do anything about his concerns, describing it as a misunderstanding and saying the resident kept changing his story. RN #1 confirmed Resident #34 reported the incident to her, acknowledged it was resident-to-resident abuse, and admitted she did not document or report it to anyone. The Ombudsman also confirmed she spoke with the Administrator about the complaint and was told the facility had other complaints about the alleged perpetrator.
Failure to Use EBP and Properly Disinfect Glucometer During Medication Care
Penalty
Summary
The facility failed to prevent the spread of infection during medication administration by not ensuring Enhanced Barrier Precautions (EBP) were used and by not properly cleaning and disinfecting a multi-use glucometer for two residents. Facility policy stated that EBP are used to prevent the spread of multidrug-resistant organisms and that high-contact care activities such as device care or use, including feeding tube care, require gown and glove use. Resident #21 had a PEG tube and was under EBP, with PPE hanging on the room door, but an LPN entered the room and administered medications through the PEG tube without donning a gown. During interview, the LPN acknowledged that residents with PEG tubes are under EBP and that she failed to wear a gown while providing the medication administration. For Resident #40, an RN performed an Accu-Check using a multi-use glucometer and placed it on the medication cart and then into a basket without disinfecting it. When questioned, the RN initially used an alcohol swab and stated she may not have cleaned it correctly because disinfectant wipes were unavailable, then later retrieved bleach germicidal wipes from the cart drawer and wiped the glucometer. The glucometer was then placed back on top of the medication cart without a clean barrier. Facility policy required reusable blood glucose meters to be cleaned and disinfected between resident uses with an EPA-registered disinfectant. The interim DON stated the glucometer should have been cleaned and disinfected appropriately and that cleaning with only alcohol swabs was not acceptable.
Failure to Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
Failure to obtain a PAS for a resident with mental health diagnoses led to the deficiency. Facility policy stated that all new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders through the Medicaid PASARR process. Staff interviews confirmed that the resident was admitted for therapy with an expected discharge home within 30 days, but the therapy stay was extended. The Social Worker acknowledged the resident had diagnoses of bipolar disorder and anxiety disorder and confirmed the facility did not submit a PAS for a resident who remained in the facility for greater than 30 days. The Administrator also acknowledged that PAS is part of the process to ensure residents are appropriate for nursing home care and confirmed the required PAS was not completed. Record review showed the resident’s admission record listed bipolar disorder and anxiety disorder, and the MDS dated 6/24/25 showed a BIMS score of 15, indicating the resident was cognitively intact.
Failure to Develop and Follow Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with PTSD and bipolar disorder, and for another resident with anxiety disorder and bipolar disorder, despite both residents having these diagnoses documented in their records and being cognitively intact. For the resident with PTSD, the care plan did not address past traumatic events or potential triggers. During interview, the resident stated he was a veteran, had PTSD, experienced nightmares, and was bothered by crowded areas, noise, and loud environments. Social Services and the Interim DON confirmed the resident did not have a care plan for PTSD and that staff needed guidance on triggers and distressing situations. The facility also failed to implement the care plan for a resident ordered nectar-thick liquids. The resident’s care plan included dysphagia and diet restrictions, and the order summary specified a dysphagia mechanical soft diet with nectar consistency and ground meats. During a lunch observation, the resident was served a carton of regular 2% milk with a straw instead of thickened milk. Dietary staff confirmed the milk was the wrong consistency, and the MDS nurse stated the care plan was not followed in relation to nectar-thick liquids. In addition, the resident with anxiety disorder and bipolar disorder did not have a care plan developed for those mental health diagnoses, and the MDS coordinator and Administrator acknowledged the omission.
Failure to Assess PTSD Triggers
Penalty
Summary
The facility failed to assess and identify potential triggers for a resident with PTSD and trauma history. Resident #5, a cognitively intact veteran with diagnoses including PTSD and schizoaffective disorder, bipolar type, was observed lying in bed with the curtains closed and the room dark. During interview, he stated he suffered from depression, took an antidepressant, had served in the [NAME] Corps for 17 years, and was diagnosed with PTSD after having to kill people during service. He reported nightmares, trouble sleeping, and that almost everything bothered him, including crowded areas, noise, and loud environments. Record review showed the resident’s psychiatry note documented his military history, prior suicidal behavior after leaving the military, and ongoing nightmares, with PTSD diagnosed. The facility policy on Trauma-Informed and Culturally Competent Care stated it was intended to guide staff in minimizing triggers and/or re-traumatization. However, the record showed no trauma assessment had been completed for the resident. Social Services staff confirmed she was responsible for trauma-informed care assessments and stated she learned in January 2025 that the resident had PTSD after the nurse practitioner saw him, but no assessment had been done to inform staff about his PTSD and potential triggers. The Interim DON stated trauma assessments should be conducted quarterly to ensure psychosocial needs and mental well-being were met.
Medication administration error rate exceeded allowable threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% by not ensuring that residents received all physician-ordered medications during medication administration observations. Based on observation, staff interview, record review, and policy review, three of 28 medication administration opportunities were in error, resulting in a medication error rate of 10.71%. The facility policy titled Medication Administration stated that medications are to be administered as prescribed in accordance with written physician orders. During a medication pass observation on 8/06/2025, an RN administered nine medications to a resident with diagnoses including Type 2 diabetes mellitus, PTSD, schizoaffective disorder, bipolar type, and overactive bladder. Record review of the Order Summary Report and Medication Admin Audit Report showed that three ordered medications were not given at that medication administration time: Metformin HCI 500 mg, Oxybutynin Chloride ER 10 mg, and Risperdal 0.5 mg. The audit report showed those three medications were documented as given at 09:38 and 09:40 during the observation. The interim DON stated that nurses are expected to administer all physician-ordered medications and that if a medication is unavailable, the nurse must call the physician and notify the DON. The RN later stated she returned after the medication pass and gave the resident the other medications. The resident’s MDS showed a BIMS score of 15, indicating the resident was cognitively intact.
Therapeutic Diet Not Served as Ordered
Penalty
Summary
The facility failed to serve a therapeutic diet as ordered for one resident reviewed for the dining task. During lunch observation, the resident was served a meal that included a carton of regular 2% milk with a straw inserted, even though the meal ticket noted nectar liquids and nectar milk. Dietary staff later brought nectar-thickened milk to the tray and removed the regular milk, and the staff member confirmed the resident had initially been served regular milk. She stated she noticed the error while assisting another resident and acknowledged that aspiration was a possible risk. She also said a new tray line server was still in training and that the server should be reading tray cards before sending trays to the dining room. The resident had an order for dysphagia mechanical soft texture with nectar consistency and ground meats. The interim DON stated certified nurse aides were expected to check the meal ticket against the food provided at mealtime to ensure the correct diet was served, and she confirmed the resident was on nectar liquids. The speech therapist stated the resident was on the speech therapy caseload due to poor dentition and a history of aspiration pneumonia, and that thickened liquids were maintained because the resident’s condition fluctuated and she experienced seizure episodes. The resident’s record also showed diagnoses of dementia with anxiety, dysphagia, and conversion disorder with seizures or convulsions, and an MDS BIMS score of 4 indicating severe cognitive impairment.
Failure to Secure Medication Keys Led to Misappropriation of Controlled Substance
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically regarding the resident's controlled medication. Facility policy required that controlled substances be securely locked and that medication keys remain in the possession of the nurse at all times. However, an LPN left the medication keys unattended on the nurses' station desk while taking a break and later left the keys on the medication cart while a corporate nurse was checking for expired medications. These actions provided an opportunity for unauthorized access to controlled substances. The incident was discovered when the LPN attempted to retrieve a PRN pain medication for a resident and found that a card containing 30 Norco (Hydrocodone) tablets was missing. The LPN reported the missing medication to the nurse supervisor, and a search was conducted, but the medication was not located. Interviews confirmed that the LPN had been previously trained and in-serviced on the importance of keeping medication keys secured and was aware of the policy but failed to follow it on the day of the incident. The resident involved had a history of significant medical issues, including a displaced midcervical fracture of the left femur, aftercare following joint replacement surgery, and dementia, with a moderate cognitive impairment as indicated by a BIMS score of 11. The missing medication was part of the resident's prescribed pain management regimen. The facility's failure to ensure the security of controlled substances resulted in the misappropriation of the resident's medication.
Failure to Remove Nurse During Medication Misappropriation Investigation
Penalty
Summary
The facility failed to prevent further potential medication misappropriation by allowing a nurse to continue working during an active investigation into missing narcotic medication. According to facility policy, any employee accused of resident abuse or misappropriation is to be placed on leave with no resident contact until the investigation is complete. However, after a 30-count card of Hydrocodone was reported missing for a resident, the nurse responsible for the medication cart was not removed from duty. She admitted to leaving the medication cart keys unattended on multiple occasions during her shift, and the missing medication was reported in the afternoon. Despite this, she continued to complete her assignment, including medication passes, and was not instructed to turn in her keys or leave the facility during the investigation. Interviews with facility administration confirmed that the nurse remained on duty and maintained access to the medication cart throughout her shift and the subsequent shift, even after the missing medication was reported. The police were notified and responded to the incident, and the nurse was drug tested but allowed to return to her duties. Review of time cards and controlled drug count records corroborated that the nurse was present and responsible for the medication cart during the period in question. The facility acknowledged that it did not follow its own policy to prevent further potential misappropriation by not removing the nurse from resident care during the investigation.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one of the residents. The incident involved a Certified Nursing Assistant (CNA) who allegedly hit a resident in the face with a closed fist during a commotion in the dining room. A Licensed Practical Nurse (LPN) witnessed the aftermath and was informed by another CNA about the incident. However, the LPN did not report the incident immediately as required by the facility's policy. The LPN attempted to report the incident to the Director of Nursing (DON) but was unable to find her and subsequently got sidetracked by other duties. The LPN eventually reported the incident the following day via text message to the DON. The delay in reporting the incident was a violation of the facility's policy, which mandates that allegations of abuse should be reported within two hours if there is serious bodily injury or within 24 hours if there is no injury. The resident involved in the incident had severe cognitive deficits, as indicated by a Brief Interview for Mental Status (BIMS) score of 04. The resident's medical history included dementia, schizophrenia, restlessness, and agitation. Despite the serious nature of the allegation, the incident was not reported to the appropriate authorities until nearly a month later, when the facility administrator was informed by another CNA who overheard a conversation about the incident.
Significant Medication Error Involving Wrong Medication Administered to Resident's Eye
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident where a Licensed Practical Nurse (LPN) mistakenly instilled a drop of mometasone furoate scalp solution into a resident's left eye instead of the physician-ordered eye drops. The error occurred when the LPN, who was not accustomed to working the medication cart, picked up the wrong bottle from the resident's bedside table. The resident immediately complained of a burning sensation in her eye, prompting the LPN to contact the Medical Director, who instructed her to flush the eye with normal saline. The resident's eye was assessed multiple times, showing no redness or abnormal drainage, but the resident reported continued discomfort for a couple of days and sought further medical attention on her own. The resident involved had a history of Segmental and Somatic Dysfunction of the Cervical Region, Quadriplegia, and Morbid Obesity, and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident had both eye drops and scalp treatment medications in her room, which contributed to the confusion. The LPN had placed the eye drops on the right bedside table and the scalp drops were on the overbed table, but she mistakenly picked up the scalp drops after administering the oral medications. The Director of Nursing (DON) confirmed the incident and acknowledged that the presence of the scalp drops in the resident's room was a contributing factor. The DON noted that the LPN had called the Medical Director immediately and followed his instructions to flush the eye. The incident was documented in the resident's records, and the responsible party was notified. The facility's policy on medication errors was reviewed, which defined medication errors and provided examples, including wrong route of administration, such as ear drops given in the eye.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure proper storage of medication as evidenced by a tube of Hydrocortisone Topical Cream being left on a resident's overbed table. The resident, who was unable to self-administer medication due to physical limitations, had the cream within reach on her bedside table. The facility's policy mandates that medications should be stored securely and only accessible to authorized personnel unless a resident has been evaluated and deemed competent to self-administer. However, the resident had not been evaluated for self-administration and had a history of keeping medications in her room against facility policy. Interviews with staff confirmed that the resident often brought medications back from appointments without informing the staff, and previous incidents had occurred where medications were found in her room and had to be removed and locked up by the nursing staff. The Director of Nursing (DON) and Registered Nurse (RN) confirmed that the resident was not capable of self-administering medications and that the Hydrocortisone cream should have been locked in the medication cart. The DON acknowledged that leaving medications in the resident's room posed a risk of medication errors, as evidenced by a previous incident where the resident received the wrong medication. The facility's failure to adhere to its medication storage policy resulted in the Hydrocortisone cream being improperly stored, creating a potential risk for medication errors and unauthorized access by other residents.
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Illustrative
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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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Illustrative
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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) |
|---|---|---|---|---|
| Dugan Memorial Home | 1 mi | ★★★★★ | 3 | 0 |
| Baptist Memorial Hospital Gt | 13.4 mi | — | 0 | 0 |
| Vineyard Court Nursing Center | 13.7 mi | ★★★★★ | 3 | 0 |
| Care Center Of Aberdeen | 14.7 mi | ★★★★★ | 8 | 0 |
| Starkville Manor Health Care And Rehabilitation Ce | 14.8 mi | — | 10 | 0 |
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