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 Wind Village during CMS and state inspections, most recent first.
Failure to Use EBP for Resident With Chronic Wound: A resident with a chronic open stump wound, dependence for ADLs, and ongoing wound care was not placed on EBP. During observed wound care, an LPN wore gloves but no gown, there was no EBP sign on the door, and no gowns were available in or outside the room. Staff stated they did not believe gowns were needed, and the IP confirmed EBP had not been implemented for the resident.
Failure to assess and track a resident’s declining ROM led to a contracted hand, pain, and difficulty using a walker. OT, PT, the RN, DON, and MD all noted the decline was not reported or followed up, and the resident was observed with curled fingers and pain on ROM. The facility also lacked documentation that ordered ROM, PROM, standing, ambulation, and restorative programs were being carried out for multiple residents, with staff reporting the restorative process was not functioning and tasks were not appearing in the computer system.
Failure to report decline in right-hand ROM: A resident with cognitive impairment, ESRD, cancer, and HTN developed worsening right-hand tightness and contractures, but staff did not notify the MD, resident representative, or therapy. The resident was observed using only the left hand with a walker and when sitting, and OT found significant contractures and pain when opening the fingers. An NA and an LPN acknowledged the decline had been present for months, while the DON and MD said they were unaware or did not recall being informed.
A resident with moderate cognitive impairment and multiple medical diagnoses left the building unattended and was found in the parking lot. Although the resident was identified as at risk for wandering and a wander guard was placed, the record lacked a follow-up elopement assessment and the care plan contained only limited wandering interventions. Staff and the DON stated the resident wanted to sit outside and that no additional care-planned interventions were in place after the elopement.
The facility failed to submit complete and accurate direct care staffing information to CMS for Quarter 1. The PBJ Report identified several dates without 24-hour licensed nurse coverage. A review of staffing schedules and time cards showed discrepancies with the PBJ report. The DON and RNQC confirmed the findings, indicating incorrect PBJ report entries by SFHS.
The facility failed to ensure proper hand hygiene and PPE use for two residents under enhanced barrier precautions, did not implement its water management plan to prevent Legionella, and did not prevent contamination during water pitcher pass. Additionally, a resident's catheter drainage bag and wound vac were improperly placed, risking cross-contamination.
A facility failed to ensure a resident's urinary catheter drainage bag was covered, compromising the resident's dignity. Despite the care plan and facility policy requiring the bag to be covered, multiple observations showed it was left uncovered and visible to others. Staff and family interviews confirmed the expectation for the bag to be covered.
The facility failed to maintain sufficient medication supplies and timely re-ordering, leading to a resident with severe cognitive impairment and cancer experiencing uncontrolled pain and being sent to the emergency room. Staff interviews revealed a lack of awareness and training on the use of the emergency medication kit, and facility policies were found to be inadequate.
Failure to Use EBP for Resident With Chronic Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic open wound on the right stump. The resident was cognitively intact, dependent on staff for dressing and ADLs, and had diagnoses that included an unhealed pressure ulcer, vascular disease, hemiplegia, and an acquired absence of the right leg below the knee. The resident’s care plan identified the need for assistance with ADLs, transferring, and bed mobility, but it did not include information regarding EBP. Physician orders and wound documentation showed the resident had an ongoing wound on the right stump that required regular dressing changes and monitoring. The wound had been present for months and was described in progress notes and skin assessments as a stage two pressure ulcer or chronic wound that was improving but still open. Orders included cleansing the wound, applying wound products such as PluroGel, Prisma, Medi-honey, silver alginate, and bordered foam dressings, with monitoring for signs of infection. During observation of wound care, an LPN sanitized supplies, washed hands, and applied gloves, but did not apply a gown. There was no EBP sign on the resident’s door and no gowns outside or inside the room. The LPN stated gowns were used for residents with MRSA or another organism that warranted gowns, but did not believe gowns were needed for this dressing change. A NA also stated she did not wear a gown when providing ADLs because the resident did not have C. diff or a contagious organism and was not on EBP. The IP confirmed the resident had not been placed on EBP and staff had not been wearing gowns during dressing changes. The DON stated staff were expected to use EBP for residents with chronic wounds during high-contact care such as transfers, dressing, wound changes, and ADLs.
Failure to Assess ROM Decline and Provide Ordered Restorative Programs
Penalty
Summary
The facility failed to assess, implement, and evaluate a resident’s loss of ROM for one resident who was observed with a contracted right hand, increased pain, and difficulty ambulating with a walker. The resident had a significant change MDS showing moderate cognitive impairment, hypertension, ESRD, and need for moderate assistance with ADLs, including bed mobility, toileting, and transfers. The resident’s care area assessment identified physical limitations and risk for contractures, and the care plan noted impaired balance and right-sided upper extremity weakness with PT/OT involvement as needed. OT documentation showed the resident had been discharged with a recommendation for a functional maintenance program for the right shoulder and elbow, but the record lacked evidence that the program was initiated. PT later documented concern that the resident was not using the right arm after a CVA history and that she tended to rest the right hand on the walker rather than hold it, but the resident declined a platform walker trial and there was no further follow-up or additional intervention related to the right hand. During two observations, the resident was seen pushing a front wheeled walker with the left hand while the right hand remained at her side with curled fingers. When OT opened the fingers, the resident yelled that it hurt, and OT found significant contractures of the thumb and all four fingers, along with redness at the thumb tip and pain during ROM assessment. Staff interviews showed multiple employees had noticed the resident’s right hand tightening and curling over the prior months, but they did not report the decline because they assumed the facility was already aware. The resident stated she was having more difficulty walking because she could not use her right hand to push her walker. The RN, DON, and MD each stated they had not been notified of the decline in ROM or the contractures, and they expected staff to report such changes so the resident could be assessed and further decline prevented. The facility also failed to provide functional maintenance or restorative programs as ordered for multiple residents. Several residents had PT/OT orders or care plans for PROM, ROM, standing programs, or ambulation assistance, but the records lacked documentation that the programs were initiated or completed, and in several cases the care plans did not specify the extremity or frequency. Staff interviews indicated the restorative program was no longer functioning as intended, there was no restorative aide, staff were responsible for completing restorative therapy, and the computer task system did not show restorative programs for residents who had them ordered. The DON confirmed staff were expected to follow the Kardex and care plan to complete exercises, but the restorative therapy orders were not linking to tasks for documentation.
Failure to Report Decline in Right-Hand ROM
Penalty
Summary
The facility failed to notify the physician and the resident representative of a significant decline in range of motion for a resident with moderate cognitive impairment, cancer, hypertension, and end stage renal disease. The resident required moderate assistance with activities of daily living, had right-sided upper extremity impairment, and the care plan identified self-care deficits related to impaired balance and right-sided upper extremity weakness, but it lacked evidence of decreased ROM to the right hand. During observations, the resident was seen walking with a front wheeled walker while the right hand remained down at the side with the fingers curled inward, and the resident used only the left hand to push the walker and to sit in a recliner. During an OT observation and interview, the OT opened the resident's right-hand fingers and the resident yelled that it hurt; the OT then assessed significant contractures of the thumb and all four fingers and stated that when the resident was admitted six months earlier there had only been slight tightness and no contractures. The OT stated she had not been notified of the decline in ROM and expected staff to notify therapy and the physician. An NA and an LPN both stated the resident had worsening difficulty opening the right hand over the prior months, with the NA reporting the resident had complained of pain for about two months, but neither had reported the change. The resident and a family member also stated the decline had been noticed in recent months, while the DON and MD stated they were unaware of the decline or did not recall being notified.
Failure to Reassess and Plan for Resident Elopement Risk
Penalty
Summary
The facility failed to re-assess and develop interventions for a resident at risk for elopement after the resident left the building without staff knowledge. The resident had a significant change MDS assessment identifying moderate cognitive impairment and diagnoses including cancer, hypertension, and end stage renal disease, and required moderate assistance with ADLs including bed mobility, toileting, and transfers, with impairment on one side of an upper extremity. The care plan identified the resident as at risk for wandering and noted a wander guard, but the interventions were limited and did not include additional measures related to wandering. The resident’s elopement risk assessment stated the resident had no desire to leave and was not at risk to wander or elope. A progress note documented that the resident went out the back door unattended and was found in the parking lot by a family member of another resident, then escorted back inside by staff. The resident’s family was notified and a wander guard was placed on the resident, but the medical record lacked evidence of any follow-up elopement assessment. Staff interviews reflected that the resident had gone outside without staff, wanted to sit outside, and that the only care-planned intervention after the incident was the wander guard. The NM and DON both stated that a new elopement risk assessment should have been completed and additional care-planned interventions should have been implemented, but neither had occurred.
Failure to Submit Accurate Staffing Information
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1. The Payroll Based Journal (PBJ) Report identified several dates where the facility did not have licensed nurse coverage for 24 hours per day. A review of staffing schedules and time cards from 10/15/23 through 12/31/23 showed that 14 staff members, including registered nurses (RNs) and licensed practical nurses (LPNs), had worked on the dates in question. However, there was a discrepancy between the staffing schedules, time cards, and the PBJ report. During an interview, the Director of Nursing (DON) and the Registered Nurse Quality Consultant (RNQC) confirmed these findings and indicated that the PBJ reports had not been entered correctly by St. [NAME] Health Services, Inc. (SFHS). The facility's policy stated that the Employment System Department (ESD) would review all PBJ data for accuracy and submit it before the CMS-mandated deadline.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure appropriate hand hygiene and the proper use of personal protective equipment (PPE) for two residents under enhanced barrier precautions. Observations revealed that nursing assistants did not wear gowns and gloves or perform hand hygiene while assisting residents colonized with Methicillin-resistant Staphylococcus aureus (MRSA) with activities such as toileting and changing briefs. Both the infection preventionist and the director of nursing confirmed that staff had been educated on enhanced barrier precautions but did not adhere to the protocols during the observed care activities. The facility also failed to implement its water management plan to prevent the growth and spread of Legionella in the facility's water system. Observations of an indoor river in the facility showed standing water with white residue, reflective film, and green slime, indicating biofilm buildup. The maintenance director confirmed that the river had not been running for over a year and that water was only added weekly, contrary to the daily addition required by the Legionella prevention checklist. The director of nursing and the infection preventionist were aware of the issue but indicated that the resolution had stalled at the corporate level. Additionally, the facility did not ensure that water pitchers were delivered in a manner that prevented contamination. During water pitcher pass, dietary aides and job coaches did not sanitize their hands between handling clean and dirty water jugs, and the straws on the water jugs were not covered. The dietary manager and infection preventionist confirmed that the staff had not received proper training on infection control practices. Furthermore, a resident's urinary catheter drainage bag and wound vac were observed touching the floor, which was confirmed by nursing staff as improper practice that could lead to cross-contamination.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure urinary catheter drainage bags were covered to maintain the dignity of a resident (R25). R25, who had diagnoses of multidrug-resistant organism, dementia, and renal failure, was observed multiple times with an uncovered urinary catheter drainage bag. The care plan for R25 indicated that the urinary catheter drainage bag should be covered with a privacy bag when the resident was in a wheelchair or in bed. However, observations on different occasions showed that the urinary catheter drainage bag was not covered, visible to other residents, staff, and visitors, and even touching the floor at one point. Interviews with family members and staff confirmed that the urinary catheter drainage bag should have been covered to maintain the resident's dignity, as per the facility's policy on catheter care issued on 9/11/23. During interviews, a family member expressed that R25 would be embarrassed without the privacy bag covering the urinary catheter drainage bag. Nursing staff, including a nursing assistant and a licensed practical nurse, acknowledged that the urinary catheter drainage bag should have been covered at all times. The Director of Nursing confirmed the findings and reiterated that staff were expected to place the privacy bag over the urinary catheter drainage bag to ensure the resident's dignity. The facility's policy emphasized maintaining catheter patency, preventing infection, and ensuring dignity by covering the drainage bag with a cloth or vinyl bag.
Failure to Ensure Sufficient Medication Supplies and Timely Re-ordering
Penalty
Summary
The facility failed to ensure procedures were implemented and followed to maintain sufficient medication supplies, timely medication re-ordering, and appropriate actions when a medication was unavailable for administration. This deficiency was highlighted by the case of a resident with severe cognitive impairment and multiple diagnoses, including cancer, who did not receive his scheduled Oxycodone due to a lack of supply. The resident experienced uncontrolled pain and was sent to the emergency room, with no evidence that staff followed up with the pharmacy or notified the provider in a timely manner. Interviews with various nursing staff revealed a lack of awareness and understanding of the facility's emergency medication kit and the procedures for its use. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) interviewed were unable to recall why the medication was not refilled and were unaware of the medications available in the emergency kit or the policy on its use. The Director of Nursing (DON) also confirmed the lack of knowledge and training regarding the emergency kit and the process for obtaining medications when the pharmacy was unavailable. The facility's policies on medication administration and the emergency kit were found to be inadequate. The Medication Administration policy lacked procedures for handling situations when a medication was unavailable, and the Emergency Kit policy did not provide clear steps for staff to follow. Additionally, a review of nurse staff education revealed no specific training on the use of the emergency kit, further contributing to the deficiency in medication management and resident care.
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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 Morris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Minnewaska Community Health Services | 19.3 mi | ★★★★★ | 8 | 0 |
| Barrett Care Center Inc | 22.1 mi | ★★★★★ | 0 | 0 |
| Essentia Health Grace Home | 24.5 mi | ★★★★★ | 0 | 0 |
| Glenwood Village Care Center | 26.4 mi | ★★★★★ | 2 | 1 |
| Appleton Area Health | 27.1 mi | ★★★★★ | 5 | 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.