West Wind Village

In the surveyor’s words

From the most serious findings on record at West Wind Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 2, 2022

  Based on observation, interview, and document review the facility failed to implement appropriate interventions to protect 1 of 3 identified residents (R1) with wandering behaviors from leaving the facility unattended while in the COVID-19 isolation unit. As a result, R1 eloped from the facility on 5/27/22, which resulted in a potential risk of serious harm identified at immediate jeopardy. The immediate jeopardy (IJ) began on 5/26/22, when R1 was transferred from the secure locked memory care unit to the COVID-19 isolation unit. The administrator and director of nursing (DON) were notified of the IJ on 6/2/22 at 9:15 a.m. and the facility implemented corrective action on 5/27/22, prior to the start of the survey and was issued at Past Noncompliance. […]

• Actual harm, isolatedF689Aug 5, 2026

  Based on observation, interview, and document review, the facility failed to ensure a standing mechanical lift was maintained in a safe operating condition according to manufacturer's guidelines for 1 of 1 resident (R1) reviewed for accidents. The facility's failure resulted in actual harm when R1 fell from the lift and suffered a femur fracture. The facility implemented corrective measures on 7/24/26 prior to the start of the survey; therefore, the deficient practice was cited as past noncompliance.Findings includeR1's face sheet included diagnoses of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, phantom limb syndrome with pain, morbid obesity, acquired absence of left leg above knee, and muscle weakness.R1's quarterly… […]

• Actual harm, isolatedF688Jul 30, 2025

  Based on observation, interview and document review, the facility failed to assess, implement and evaluate a loss in range of motion for 1 of 1 resident (R7) reviewed for range of motion. This practice resulted in harm when R7 was observed with her right hand contracted, increased pain and difficulty ambulating with a walker. In addition, the facility failed to provide functional maintenance programs as ordered to maintain and/or prevent loss of range of motion (ROM) for 8 of 8 residents (R7, R5, R3, R11,R17,R30,R33, R39) reviewed. […]

• No harm, potential for more than minimal, widespreadF851May 1, 2024

  Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 47 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 10/21/23, 11/11/23, 11/19/23, 11/25/23, 12/2/23, 12/10/23, 12/30/23, and 12/31/23 for failure to have licensed nurse coverage 24 hours per day. […]

• No harm, potential for more than minimal, widespreadF880May 1, 2024

  Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and donning/doffing of personal protective equipment (PPE) was performed in order to prevent the spread of infection for 2 of 3 residents (R7, R29) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to implement the water management plan for the prevention of Legionella (a bacterium) in the facility water system. This deficient practice had the potential to affect all 47 residents who resided in the facility. […]