Inspection Reports for Winfield Rest Haven II Lc
1611 RITCHIE ST, KS, 67156-5252
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 27, 2025 found no deficiencies, confirming that all prior issues cited in December 2024 were corrected by the end of that month. Earlier inspections showed a pattern of deficiencies related mainly to resident assessments, care planning, safety procedures—especially securing residents during whirlpool bath use—and medication monitoring, including psychotropic drug oversight and infection control practices. Complaint investigations substantiated some issues, such as a fall causing injury due to improper safety device use and a case of physical abuse by a staff member in 2020, which led to termination and reporting to authorities. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent inspections indicating correction of previously cited deficiencies and compliance with regulatory requirements.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
205% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
40 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 27, 2025
Visit Reason
A revisit survey was conducted on 01/27/25 to verify correction of all previous deficiencies cited on 12/04/24.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 12/31/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 5
Dec 4, 2024
Visit Reason
This document is a Plan of Correction submitted by Winfield Rest Haven in response to deficiencies cited in the facility's inspection report dated 12/04/2024. It outlines corrective actions to address identified deficiencies related to resident assessments, care plans, safety procedures, and medication monitoring.
Findings
The plan addresses multiple deficiencies including inaccurate resident assessments, incomplete care plans for Enhanced Barrier Precautions and PPE use, safety concerns with whirlpool bath chair use, and psychotropic medication monitoring. The facility has implemented re-education, audits, policy revisions, and monitoring to achieve substantial compliance by specified dates.
Severity Breakdown
D: 4
G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Inaccurate coding of restraints on MDS assessments for Resident #12 and Resident #35. | D |
| Care plans lacking provisions for Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) for Residents #26 and #30. | D |
| Safety issues related to whirlpool bath chair use, including inconsistent use of safety belts. | G |
| Incomplete AIMS assessments for residents prescribed psychotropic medications, including Resident #35. | D |
| Noncompliance with Enhanced Barrier Precautions (EBP) procedures, including gown and glove use during high-contact care for Residents #26, #23, and #29. | D |
Report Facts
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sydney | Mentioned in relation to evaluation of restraint coding inaccuracies | |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Melissa Parmley | Administrator | Submitted the Plan of Correction |
| Jessica Patterson | Added Plan of Correction on 12/17/2024 | |
| Lori Mouak | Modified Plan of Correction on 02/11/2025 |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 5
Dec 4, 2024
Visit Reason
The inspection was a Health Resurvey and investigation of complaints 190978 and 190727.
Findings
The facility failed to ensure accuracy of resident assessments, timely and comprehensive care plan revisions, proper use of safety devices, appropriate monitoring of psychotropic medication use, and adherence to infection prevention protocols including enhanced barrier precautions.
Complaint Details
The visit was triggered by complaints 190978 and 190727, focusing on assessment accuracy, care planning, accident prevention, medication monitoring, and infection control.
Severity Breakdown
SS=D: 4
SS=G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure accuracy of Minimum Data Set (MDS) assessments for two residents regarding impairment and restraint use. | SS=D |
| Failed to review and revise care plans timely for residents with enhanced barrier precautions related to catheters and nephrostomy tubes. | SS=D |
| Failed to ensure staff secured resident in whirlpool bath chair resulting in fall and injury requiring sutures. | SS=G |
| Failed to monitor resident for adverse reactions to antipsychotic medications including lack of required AIMS assessments. | SS=D |
| Failed to ensure staff donned appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions to prevent infection spread. | SS=D |
Report Facts
Census: 40
Residents reviewed: 14
Fall Risk Score: 13
Sutures required: 8
AIMS assessment date: Oct 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed inaccurate MDS coding and expectations for safety belt use and medication monitoring | |
| Administrative Nurse D | Confirmed expectations for safety belt use and enhanced barrier precautions | |
| Administrative Nurse E | Observed not wearing required PPE during catheter care for resident R26 | |
| Certified Nurse Aide P | Observed not wearing required PPE during catheter care for resident R26 | |
| Certified Nurse Aide MM | Admitted to not consistently using whirlpool bath chair safety belt for resident R35 | |
| Consulting Staff GG | Confirmed MDS completion practices and care plan expectations | |
| Certified Nurse Aide Q | Provided information on resident positioning rail use |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 22, 2023
Visit Reason
An offsite revisit survey was conducted on 03/22/2023 for all previous deficiencies cited on 02/15/2023 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 03/02/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 4
Feb 15, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during the inspection visit on 2023-02-15 at Winfield Rest Haven.
Findings
The facility identified multiple deficiencies including failure to properly implement standing orders for oxygen, incomplete hospice service orders in medical records, failure to follow residents' fall interventions as care planned, and improper storage of supplies. Corrective actions and staff education were implemented to address these issues.
Severity Breakdown
D: 4
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement standing order for oxygen and notify physician of changes in condition | D |
| Incomplete medical records for hospice services | D |
| Failure of direct care staff to follow residents' fall interventions as care planned | D |
| Improper storage of supplies including storage boxes on the floor and broken vinyl | E |
Report Facts
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Stein | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 5
Feb 15, 2023
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify a physician of a resident's change in condition requiring oxygen, failure to have an order for hospice care for a resident receiving hospice services, failure to follow fall prevention interventions resulting in a non-injury fall, failure to obtain an order for oxygen use for a resident, and failure to maintain a safe and sanitary environment due to improper storage of supplies on the floor.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify the physician of a resident's change of condition regarding the need for oxygen implementation. | SS=D |
| Failed to ensure a resident's medical record contained an order for hospice care following admission. | SS=D |
| Failed to follow fall interventions resulting in a non-injury fall for a resident with a history of falls. | SS=D |
| Failed to obtain an order for oxygen for a resident requiring PRN oxygen usage. | SS=D |
| Failed to provide a safe and sanitary environment regarding storage of supplies directly on the floor. | SS=E |
Report Facts
Census: 36
Residents sampled: 14
Oxygen liters: 2
Boxes of face shields: 1
Boxes of disposable gowns: 2
Cases of soda: 3
12-pack of soda: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Stated staff would need to initiate an order for oxygen and notify the physician |
| Administrative Staff A | Administrative Staff | Confirmed oxygen order had not been initiated and physician not notified |
| Certified Medication Aide S | Certified Medication Aide | Stated resident received hospice care and staff were not to leave resident unattended |
| Certified Nurse Aide N | Certified Nurse Aide | Stated resident received hospice care and staff were to transfer resident when leaving room |
| Licensed Nurse G | Licensed Nurse | Stated resident was on hospice and should not be left unattended in wheelchair |
| Certified Nurse Aide M | Certified Nurse Aide | Stated resident had oxygen concentrator and used oxygen from time to time |
| Certified Medication Aide R | Certified Medication Aide | Stated resident required oxygen during night of 02/12/23 |
| Housekeeping Staff U | Housekeeping Staff | Stated supplies should not be stored directly on the floor |
| Maintenance Staff U | Maintenance Staff | Revealed areas where supplies were stored on the floor |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 29, 2021
Visit Reason
An offsite revisit survey was conducted on 10/29/2021 for all previous deficiencies cited on 08/25/2021.
Findings
All deficiencies have been corrected as of the compliance date of 09/24/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 25, 2021
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of Winfield Rest Haven on August 25, 2021.
Findings
The plan addresses deficiencies related to the process of issuing Skilled Nursing Facility advanced beneficiary notices (ABN) and Notice of Medicare Non Coverage (NOMNC) to residents coming off Medicare Part A stays, ensuring timely notification and proper documentation to beneficiaries or their representatives.
Deficiencies (1)
| Description |
|---|
| Failure to properly issue notices to residents coming off Medicare Part A services with remaining benefit days. |
Report Facts
Deficiency ID: 582
Inspection Report
Re-Inspection
Census: 20
Deficiencies: 3
Aug 25, 2021
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with Medicaid/Medicare coverage and liability notice requirements.
Findings
The facility failed to provide the Notification of Medicare Non-Coverage (NOMNC) when all covered services ended for coverage reasons and failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) in a timely manner for certain residents. Additionally, the facility failed to submit a claim or appeal to Medicare A upon request for one resident.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide NOMNC when all covered services ended for coverage reasons for residents R18, R71, and R72. | SS=D |
| Failure to issue SNFABN in a timely manner for residents R18 and R71. | SS=D |
| Failure to submit a claim/appeal to Medicare A upon request of resident R71. | SS=D |
Report Facts
Census: 20
Last Covered Day (LCD) of Medicare Part A services: Feb 23, 2021
Last Covered Day (LCD) of Medicare Part A services: Feb 1, 2021
Last Covered Day (LCD) of Medicare Part A services: Feb 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative A | Verified discrepancies related to Medicare notices and claim submissions |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 26, 2021
Visit Reason
An offsite revisit was conducted on 01/26/2021 for all previous deficiencies cited on 11/17/2020.
Findings
All deficiencies have been corrected as of the compliance date of 12/30/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 4
Nov 17, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the COVID survey conducted on 11/17/2020 at Winfield Resthaven.
Findings
The plan outlines corrective actions including holding Quality Assurance/Assessment Committee meetings, adherence to the Antibiotic Stewardship program with logs for October and November, and completion of CDC Infection Prevention training by the Director of Nursing who is now the Certified Infection Control Preventionist.
Deficiencies (4)
| Description |
|---|
| Statement of deficiencies to be taken to the facilities Quality Assurance/Assessment Committee. |
| Facility to hold QAPI/QAA meeting on 12/29/2020 and quarterly thereafter. |
| Facility to adhere to the Antibiotic Stewardship program with October and November logs initiated and completion by 12/29/2020. |
| Director of Nursing completed the CDC Train Infection Prevention and Control Program on 11/22/2020 and is now the Certified Infection Control Preventionist. |
Report Facts
Date: Dec 29, 2020
Date: Nov 22, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amie Chandler | RN DON | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Census: 22
Deficiencies: 3
Nov 17, 2020
Visit Reason
The inspection was a Targeted Infection Control Survey/COVID-19 Focused Survey conducted by the Kansas Department for Aging and Disability Services on behalf of CMS.
Findings
The facility failed to hold required quarterly Quality Assessment and Assurance (QAA) committee meetings, did not consistently utilize an antibiotic stewardship program including tracking and monitoring antibiotic use, and failed to designate a qualified infection preventionist with specialized training as required.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility quality assessment and assurance committee failed to meet at least quarterly to identify issues and develop corrective actions. | SS=F |
| Facility failed to consistently utilize an antibiotic stewardship program that included tracking and monitoring of antibiotic use. | SS=F |
| Facility failed to designate one or more individuals as infection preventionist responsible for the Infection Prevention and Control Program who had completed specialized training. | SS=F |
Report Facts
Census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding lack of QA meetings and incomplete infection control logs |
| Administrative Staff Nurse D | Administrative Staff Nurse | Responsible for Infection Prevention and Control Program, lacked certification as Infection Preventionist |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 25, 2020
Visit Reason
A non-compliance revisit was conducted on 08/25/2020 for all previous deficiencies cited on 06/22/2020.
Findings
All deficiencies have been corrected as of the compliance date of 07/22/2020 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 25, 2020
Visit Reason
A targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on August 25, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 25, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID-19 survey conducted at the facility.
Findings
The COVID-19 survey was deficiency free, indicating no deficiencies were found during the inspection.
Deficiencies (1)
| Description |
|---|
| Deficiency Free Covid 19 survey. |
Inspection Report
Plan of Correction
Deficiencies: 4
Jun 22, 2020
Visit Reason
The document is a Plan of Correction responding to citation findings from a COVID-19 survey conducted on 06/22/2020 at the facility.
Findings
The plan addresses deficiencies related to mask usage by residents when staff provide care, staff training, signage placement, and ongoing surveillance by department heads and supervisors to ensure corrections are sustained.
Deficiencies (4)
| Description |
|---|
| Masks are always to be worn by residents when staff is providing care, including when staff enters occupied rooms for various tasks. |
| Staff signature pages provided regarding plan of correction. |
| New employees will be given information on policies and procedures prior to employment. |
| Department heads and supervisors will complete surveillance for three months to assure corrections and provide additional training as needed. |
Report Facts
Plan of Correction completion date: Jul 24, 2020
COVID-19 survey date: Jun 22, 2020
Surveillance duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dereck Hutchison | Administrator, MHA | Submitted the Plan of Correction to KDADS |
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 1
Jun 22, 2020
Visit Reason
A Targeted Infection Control/COVID-19 Survey was conducted by Kansas Department for Aging and Disability Services (KDADS) on behalf of CMS from 06/17/2020 through 06/22/2020 to assess compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility failed to follow CMS and CDC recommended practices to prevent transmission of COVID-19 by not providing face masks to four residents prior to staff providing direct care, increasing the risk of virus transmission to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide face masks or facial coverings to four residents prior to staff providing direct care, increasing risk of COVID-19 transmission. | SS=F |
Report Facts
Resident census: 30
Residents without masks: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA P | Certified Nurse Aide | Reported staff failed to apply face masks to residents R5 and R6 and acknowledged staff sometimes forget to apply masks during care |
| CNA S | Certified Nurse Aide | Observed providing care without placing masks on residents |
| CNA O | Certified Nurse Aide | Reported staff must place masks on residents during care |
| Certified Nurse Aide M | Certified Nurse Aide | Reported residents should wear face masks during care |
| Certified Nurse Aide N | Certified Nurse Aide | Reported residents should wear face masks during care |
| Administrative Nurse C | Administrative Nurse | Reported residents remain in rooms when quarantined and should wear masks during care |
| Licensed Nurse G | Licensed Nurse | Reported all residents should wear face masks when staff provide care |
| Administrative Nurse B | Administrative Nurse | Reported expectation that staff place masks on residents prior to care |
Inspection Report
Re-Inspection
Deficiencies: 0
May 28, 2020
Visit Reason
An offsite revisit was conducted on 05/28/2020 for all previous deficiencies cited on 02/02/2020.
Findings
All deficiencies have been corrected as of the compliance date of 03/11/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
May 14, 2020
Visit Reason
An offsite revisit was conducted on 05/14/2020 for all previous deficiencies cited on 02/12/2020.
Findings
All deficiencies have been corrected as of the compliance date of 03/12/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 12, 2020
Visit Reason
The document is a Plan of Correction responding to citation findings from a Health Resurvey conducted on February 12, 2020.
Findings
The plan addresses deficiencies related to abuse and neglect policies, employee conduct, and resident assessments, including termination and suspension of involved employees and notification of law enforcement.
Deficiencies (1)
| Description |
|---|
| Citation findings related to abuse and neglect policy and employee involvement in an incident. |
Report Facts
Date of Health Resurvey: Feb 12, 2020
Date of Plan of Correction completion: Mar 12, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Carothers | Terminated employee involved in the incident | |
| Thea Kilpatric | RN | Suspended employee involved in the incident |
| Dereck Hutchison | Administrator, MHA | Administrator submitting the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Feb 12, 2020
Visit Reason
This inspection was conducted as a complaint investigation (#150147) related to allegations of abuse at the facility.
Findings
The facility failed to prevent physical abuse to one resident by a night shift certified nurse aide who pushed an ice chest cart into the resident's wheelchair and right foot, causing the wheelchair to turn 90 degrees. The resident was cognitively impaired and dependent, but no injury was noted. The staff member was terminated and the incident was reported to authorities.
Complaint Details
Complaint investigation #150147 substantiated physical abuse by a certified nurse aide. The resident did not experience injury. The staff member was terminated, and the incident was reported to police, medical director, resident's physician, family, and state hotline.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent physical abuse to one resident by a certified nurse aide pushing an ice chest cart into the resident's wheelchair and foot. | SS=D |
Report Facts
Census: 35
Date of abuse incident: Feb 5, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) D | Staff member who committed the physical abuse and was terminated | |
| Administrative Nurse B | Interviewed and verified the abuse incident, involved in investigation and termination | |
| Administrative staff A | Assisted in calling and interviewing CNA D |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 3, 2020
Visit Reason
An offsite revisit was conducted on 02/03/2020 for all previous deficiencies cited on 12/12/2019.
Findings
All deficiencies have been corrected as of the compliance date of 01/17/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Feb 2, 2020
Visit Reason
The inspection was conducted as a complaint investigation (KS000149571) regarding the facility's failure to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).
Findings
The facility reported a census of 35 residents but failed to accurately report the Licensed Administrator's hours worked onsite, falsely reporting 40 hours per week when the administrator was not physically present in the building. Multiple staff interviews and timecard audits confirmed discrepancies in reported hours.
Complaint Details
The complaint alleged inaccurate reporting of the Licensed Administrator's hours on the PBJ system. The investigation confirmed the administrator was not onsite as reported, with audits and staff interviews supporting the complaint.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), specifically reporting the Licensed Administrator worked 40 hours per week but was not physically in the building. | SS=F |
Report Facts
Resident census: 35
Reported hours worked: 40
Audit review period: Payroll and timecard details reviewed for 7/1/19-9/30/19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Licensed Administrator | Named in finding for falsifying hours worked onsite reported to PBJ |
| Administrative Nurse E | Administrative Nurse | Reported concerns about Staff A's lack of hours onsite and falsification of PBJ hours |
| Administrative Assistant Staff Y | Administrative Assistant | Entered 40 hours per week for Staff A into the time system starting 07/01/2019 |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 12, 2019
Visit Reason
The document is a Plan of Correction submitted in response to citation findings from a Health Resurvey conducted on December 12, 2019.
Findings
The Plan of Correction outlines corrective actions including staff education, policy updates related to comprehensive care plans, dialysis procedures, drug regimen reviews, and medication administration to address deficiencies cited during the Health Resurvey.
Deficiencies (1)
| Description |
|---|
| Citation findings from the Health Resurvey conducted on 12/12/2019 requiring corrective actions. |
Report Facts
Date of Health Resurvey: Dec 12, 2019
Date of QA/QAPI meeting: Jan 16, 2020
Date for completion of all new policies: Jan 17, 2020
Date new consulting pharmacist begins: Jan 1, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 5
Dec 12, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #147834 and #144736 to assess compliance with regulatory requirements.
Findings
The facility failed to develop a comprehensive care plan for dialysis assessments before and after dialysis services for one resident, failed to monitor the dialysis shunt and blood pressure after dialysis, failed to identify irregularities in insulin administration by the pharmacist, failed to ensure adequate monitoring of blood pressures with diuretic medication, and failed to prevent significant medication errors related to insulin administration outside physician ordered parameters.
Complaint Details
The inspection included complaint investigations #147834 and #144736.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for dialysis assessments before and after dialysis services for one resident. | SS=D |
| Failed to monitor the dialysis shunt and blood pressure after dialysis for one resident. | SS=D |
| Consulting pharmacist failed to identify irregularity of insulin administration outside physician orders over multiple months for one resident. | SS=D |
| Failed to ensure one resident remained free of unnecessary medications related to inadequate monitoring of blood pressures with administration of diuretic medication. | SS=D |
| Failed to ensure no significant medication errors when insulin was administered outside physician ordered blood sugar parameters for one resident. | SS=D |
Report Facts
Census: 33
Residents reviewed: 14
Dialysis frequency: 3
Insulin administrations outside parameters: 14
Insulin administrations outside parameters: 25
Insulin administrations outside parameters: 27
Insulin administrations outside parameters: 19
Insulin administrations outside parameters: 15
Blood pressure readings outside parameters: 3
Blood pressure readings outside parameters: 1
Blood pressure readings outside parameters: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Confirmed failure to assess dialysis fistula and vital signs after dialysis for Resident 22 |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding dialysis assessments and medication administration irregularities |
| Licensed Nurse G | Licensed Nurse | Confirmed insulin should not have been administered when blood sugar was under 300 for Resident 21 |
| Consultant Pharmacy Staff GG | Consultant Pharmacist | Acknowledged failure to identify insulin administration irregularities in monthly medication reviews |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 11, 2019
Visit Reason
An offsite revisit survey was conducted on 02/11/2019 for all previous deficiencies cited on 12/12/2018.
Findings
All deficiencies have been corrected as of the compliance date of 01/11/2019, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 9
Dec 12, 2018
Visit Reason
This document is the Plan of Correction for the citation findings of the health resurvey conducted on 2018-12-12.
Findings
The Plan of Correction addresses multiple deficiencies including policies for Medicare Denial Notices, comprehensive and quarterly assessments, drug regimen review, and kitchen utensil sanitation and replacement.
Severity Breakdown
E: 1
D: 7
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Policy written for Medicare Denial Notices on 12-24-2018; Social Worker consultant to review ABNs monthly; SSD position open for hire. | E |
| Policy regarding comprehensive and quarterly assessments presented to staff; training new LPN on MDS completion and timeliness. | D |
| Provided policy regarding comprehensive and quarterly assessment to staff; training new LPN on MDS completion and timeliness. | D |
| Director of Nursing/Assistant Director of Nursing to review data entered into MDS to ensure accuracy. | D |
| Activity Director adopted new form titled Activities/Preferences Comprehensive Assessment to be completed upon admission. | D |
| Activity Director to follow the Activities/Preferences Comprehensive Assessment within 48 hours of admission; provided resident with amplifier and magnifying sheet. | D |
| Policy written for Drug Regimen Review; Consulting Pharmacists spoke to surveyors regarding monitoring weights and notifying physician; DON/ADON to monitor weights and blood glucose results. | D |
| Policy written for Drug Regimen Review; Consulting Pharmacist spoke with surveyors regarding monitoring weights and notifying physician; DON/ADON to monitor weights and blood glucose results. | D |
| Three cutting boards ordered and old ones discarded; new rubber spatulas ordered and received; inspection of utensils added to weekly chore list. | F |
Report Facts
Dates of policy or item orders: Policies written on 12-24-2018; cutting boards ordered on 12-16-2018 and arrived 12-24-2018; rubber spatulas ordered 12-16-2018 and arrived 12-17-2018 and 12-24-2018.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 10
Dec 12, 2018
Visit Reason
The inspection was a health resurvey to evaluate compliance with Medicare/Medicaid regulations including beneficiary notices, comprehensive assessments, care planning, medication regimen reviews, and food safety.
Findings
The facility failed to provide appropriate beneficiary notices to six residents, complete timely and accurate comprehensive assessments and care plans for several residents, ensure individualized activity programs, monitor medication regimens properly including weight and blood glucose monitoring, and maintain sanitary food service conditions in the kitchen.
Severity Breakdown
SS=E: 1
SS=D: 8
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide appropriate beneficiary notices to six sampled residents. | SS=E |
| Failed to complete comprehensive assessments timely for one resident. | SS=D |
| Failed to complete quarterly MDS timely for one resident. | SS=D |
| Failed to complete accurate comprehensive assessments for one resident. | SS=D |
| Failed to develop a comprehensive care plan including individualized activities for one resident. | SS=D |
| Failed to provide individualized activity program to maintain physical, mental, and psychosocial well-being for one resident. | SS=D |
| Consultant pharmacist failed to identify failure to monitor daily weights and notify physician for resident on diuretic therapy. | SS=D |
| Consultant pharmacist failed to identify failure to monitor blood glucose levels and notify physician for resident on insulin therapy. | SS=D |
| Facility failed to ensure drug regimen free from unnecessary drugs related to failure to monitor and notify physician of weight and blood glucose irregularities. | SS=D |
| Failed to store, prepare, distribute and serve food under sanitary conditions in the kitchen, including damaged cutting boards, spatulas, and dirty shelving with mixed storage of utensils and supplies. | SS=F |
Report Facts
Resident census: 38
Residents sampled for beneficiary notice review: 6
Residents sampled for comprehensive assessment and care plan review: 13
Weight gain incidents exceeding 2 pounds in 24 hours: 22
Blood sugar readings below ordered parameter: 8
Cutting boards with deep cuts: 3
Spatulas with missing rubber pieces: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative social services staff D | Reported failure to send required beneficiary notices | |
| Administrative nursing staff B | Verified MDS and care plan deficiencies, and medication monitoring failures | |
| Administrative nursing staff C | Verified MDS and care plan deficiencies, and medication monitoring failures | |
| Direct care staff F | Reported lack of resident activity participation | |
| Direct care staff G | Reported lack of resident activity participation | |
| Activity staff E | Verified lack of individualized care plan for activities | |
| Direct care staff H | Reported resident did not attend activities but was happy with staff interaction | |
| Consultant staff L | Reported failure to monitor weights and blood glucose levels adequately | |
| Staff I | Unaware of kitchen sanitation issues |
Inspection Report
Re-Inspection
Deficiencies: 1
Dec 12, 2018
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency at level 'F', widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2019-01-11.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Named as contact and signatory related to enforcement and survey findings. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 29, 2018
Visit Reason
An off-site survey was conducted for the deficiency cited on June 6, 2018.
Findings
The deficiency cited on June 6, 2018 was corrected as of the compliance date of June 15, 2018.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 13, 2018
Visit Reason
A complaint survey was conducted on 6/13/18 for complaint #KS00130312.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #KS00130312 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 13, 2018
Visit Reason
A complaint survey was conducted on 6/13/18 for complaint #KS00130312.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint #KS00130312 was investigated and found to be unsubstantiated with no noncompliance identified.
Inspection Report
Plan of Correction
Deficiencies: 3
Jun 11, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Winfield West Haven.
Findings
The plan addresses deficiencies related to abuse, neglect, exploitation, resident rights, and medication administration, including controlled substances and PRN medications. Staff education and policy reviews were conducted, and ongoing monitoring of PRN medication administration was established.
Complaint Details
This Plan of Correction is related to the Winfield West Haven complaint dated 06/06/2018.
Deficiencies (3)
| Description |
|---|
| Abuse, Neglect, and Exploitation and Resident Rights in-service was held on 06/11/2018. |
| Medication Administration, Controlled Substances, and PRN medication administration reviewed with Certified Medication Aides and licensed nurses. |
| Policies and education provided to staff regarding the proper protocol in administering PRN Narcotics. |
Report Facts
Date of in-service training: Jun 11, 2018
Plan of Correction effective date: Jun 15, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Caryl Gill | Modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 6, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 15, 2018.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency was an 'E' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Jun 6, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#130130) regarding possible exploitation of medications at the facility.
Findings
The facility failed to ensure four residents were free from exploitation of narcotic medications, with a total of 20 narcotic tablets signed out but not administered. Medication staff member E was found to have removed narcotic medications without proper administration documentation, leading to medication errors and exploitation.
Complaint Details
Complaint investigation #130130 focused on medication exploitation. The facility confirmed medication errors involving narcotic medications not administered as signed out, with some residents able to report missing medications.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure four residents were free from exploitation of narcotic medications, with 20 tablets signed out but not administered. | SS=E |
Report Facts
Census: 39
Narcotic tablets exploited: 20
Medication administration suspension: 60
Percocet tablets removed and signed out: 14
Percocet tablets not administered: 12
Hydrocodone-Acetaminophen doses signed out: 4
Norco tablets removed: 4
BIMS scores: Various cognitive scores for residents (6, 11, 15) indicating levels of cognition
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide | Named in medication exploitation and errors involving narcotic medications |
| Licensed Nurse R | Licensed Nurse | Conducted medication pass audit and suspended Staff E |
| Licensed Nurse B | Licensed Nurse | Investigated possible medication error related to narcotic administration |
Inspection Report
Plan of Correction
Deficiencies: 3
May 16, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 05/16/2018.
Findings
The plan addresses past noncompliance issues linked to deficiencies F0000, F655-D, and F689-J, all noted as past noncompliance with no plan of correction required at the time.
Deficiencies (3)
| Description |
|---|
| Past noncompliance related to F0000 |
| Past noncompliance related to F655-D |
| Past noncompliance related to F689-J |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
May 16, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#129472) regarding the facility's failure to develop an adequate baseline care plan and provide adequate supervision to prevent resident elopement.
Findings
The facility failed to develop a baseline care plan with interventions to prevent elopement for one resident with dementia and severe cognitive impairment. The resident eloped from the facility, walking through backyards and crossing streets before being found two blocks away. The facility also lacked adequate supervision and assistive devices to prevent the elopement and had an incomplete elopement/missing elder policy.
Complaint Details
The complaint investigation #129472 substantiated that the facility failed to prevent elopement of a resident with dementia and severe cognitive impairment. The resident left the facility unnoticed, was found two blocks away, and was returned without injury. The facility was in past noncompliance and took corrective actions including one-to-one supervision, care plan updates, policy revisions, and staff education.
Deficiencies (2)
| Description |
|---|
| Failed to develop a baseline care plan including interventions/instructions to prevent resident elopement. |
| Failed to provide adequate supervision and/or assistive devices to prevent resident from leaving the facility without staff knowledge. |
Report Facts
Census: 36
BIMS score: 6
Wandering risk score: 9
Date of admission: May 10, 2018
Date of elopement incident: May 13, 2018
Date of policy update completion: May 14, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Staff D | Reported working at time of resident elopement and provided witness statement. | |
| Licensed Nursing Staff C | Posted sign on front door warning visitors not to let residents leave unattended. |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 6, 2018
Visit Reason
A second revisit survey was conducted on 2/5-6/18 for all previous deficiencies cited on 11/30/17 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2/6/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Edwards | Named in relation to the revisit survey conducted on 2/5-6/18. |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 6, 2018
Visit Reason
A second revisit survey was conducted on 2/5-6/18 for all previous deficiencies cited on 9/29/17 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 2/6/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Nov 30, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the Winfield Rest Haven revisit inspection conducted on November 30, 2017.
Findings
The plan outlines corrective actions for multiple deficiencies including notification of resident family, fall assessments, care plan development and revision, pressure ulcer policies, accident investigations, special needs policies, and staffing documentation. Each corrective action includes policy updates, staff education, and signature verification.
Deficiencies (8)
| Description |
|---|
| Failure to notify resident family of changes and updates |
| Inadequate assessment and investigation of falls |
| Deficiencies in developing baseline and comprehensive care plans |
| Deficiencies in revising care plans |
| Inadequate policies and education regarding pressure ulcers |
| Inadequate investigation and reporting of accidents and incidents |
| Inadequate policies and education regarding special needs such as oxygen application |
| Staffing documentation deficiencies |
Report Facts
Deficiency tags referenced: 8
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 10
Nov 30, 2017
Visit Reason
The inspection was a non-compliance revisit and complaint investigation related to allegations of neglect, failure to notify family of changes, and failure to prevent falls and pressure ulcers.
Findings
The facility failed to notify a resident's responsible party of pressure ulcer development, failed to thoroughly investigate allegations of neglect related to falls, failed to follow care plans to prevent falls and pressure ulcers, failed to develop a care plan for oxygen use, and failed to post accurate nurse staffing data. Several residents experienced pressure ulcers and falls due to inadequate care and supervision.
Complaint Details
The complaint investigation included allegations of neglect, failure to notify family of changes, failure to prevent falls, and failure to provide appropriate care for pressure ulcers and oxygen therapy.
Deficiencies (10)
| Description |
|---|
| Failed to notify resident's responsible party of pressure ulcer development. |
| Failed to thoroughly investigate allegations of neglect related to falls for residents #106 and #108. |
| Failed to follow care plan interventions to prevent falls for resident #106, including failure to implement fall alarms and proper footwear. |
| Failed to develop and implement a care plan for oxygen therapy for resident #101. |
| Failed to review and revise care plans after falls for residents #106 and #101. |
| Failed to provide prompt assessment, monitoring, and treatment of pressure ulcers for resident #101. |
| Failed to provide care and services to prevent pressure ulcers and to promote healing for resident #103, including failure to reposition every 2 hours. |
| Failed to provide adequate supervision and assistive devices to prevent further falls for residents #106 and #108. |
| Failed to administer oxygen per physician orders for resident #101. |
| Failed to post nurse staffing data daily and update with actual hours worked. |
Report Facts
Resident census: 37
Fall risk score: 75
Pressure ulcer measurements: 4
Pressure ulcer measurements: 3.5
Braden skin risk score: 13
Oxygen liter flow: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Administrative Nursing Staff | Verified failure to monitor wounds and incomplete fall investigations. |
| Licensed nursing staff C | Licensed Nursing Staff | Verified care plan lacked fall intervention and reviewed fall reports. |
| Direct care staff L | Direct Care Staff | Reported resident walked short distances with assistance. |
| Direct care staff K | Direct Care Staff | Reported resident used non-skid socks and assisted with fall prevention. |
| Administrative nursing staff D | Administrative Nursing Staff | Reported unawareness of pressure ulcer prior to hospital admission. |
| Licensed nursing staff E | Licensed Nursing Staff | Reported resident oxygen titration and faxing physician for order changes. |
| Physician H | Physician | Reported resident condition not exacerbated by lack of oxygen use. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Sep 29, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #120635 and #120892 to assess compliance with federal regulations related to resident care and safety.
Findings
The facility failed to have a written agreement with an outside dialysis center for a resident receiving dialysis, failed to provide appropriate pressure relieving devices to prevent pressure ulcers for a resident at risk, and failed to provide adequate supervision and assistive devices to prevent falls, resulting in fractures for a resident.
Complaint Details
The visit was complaint-related, involving investigations #120635 and #120892. The findings included substantiated deficiencies related to dialysis coordination, pressure ulcer prevention, and fall prevention.
Severity Breakdown
Level D: 1
Level G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to have a written agreement/arrangement with the outside dialysis center for coordinated care of a resident receiving dialysis. | Level D |
| Failed to provide appropriate pressure relieving devices to prevent pressure ulcers for a resident at risk. | Level G |
| Failed to provide supervision and assistive devices and failed to determine root cause analysis after a fall to develop and implement effective interventions to prevent repeated falls resulting in fractures. | Level G |
Report Facts
Census: 37
Sample size: 13
Residents reviewed for dialysis: 1
Residents reviewed for pressure ulcers: 13
Residents reviewed for accidents: 13
Fall assessment score: 40
BIMS score: 9
BIMS score: 15
BIMS score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff L | Verified the facility had 1 resident receiving outside dialysis and lacked a contract with the dialysis center. | |
| Administrative nursing staff B | Reported unawareness of federal regulation requiring agreement with dialysis center; verified defective wheelchair cushion and lack of monitoring system; verified resident lacked non-skid socks at time of fall. | |
| Consultant staff I | Verified ineffective pressure relieving wheelchair cushion. | |
| Direct care staff J | Reported staff do not check wheelchair cushions for adequacy. | |
| Licensed nursing staff E | Reported staff do not audit wheelchair cushions; identified direct care staff should read resident's care guide daily; verified resident fell without non-skid socks. | |
| Licensed nursing staff K | Reported residents must request cushions unless therapy/restorative staff identify need. | |
| Direct care staff C | Reported resident's care guides included fall interventions. | |
| Direct care staff F | Reported resident never wears socks at night and fell in bathroom. | |
| Physician G | Physician | Discussed fall interventions and verified fractures could have been prevented if non-skid socks were applied. |
| Administrative staff A | Verified fall intervention required resident to wear non-skid socks. |
Inspection Report
Follow-Up
Deficiencies: 12
Mar 31, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were marked as completed with corrective actions accomplished by 03/01/2016.
Deficiencies (12)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(g)-(j) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.30(b) |
| Deficiency related to regulation 483.55(b) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies cited: 12
Inspection Report
Plan of Correction
Deficiencies: 15
Feb 29, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies during an inspection.
Findings
The facility identified multiple deficiencies including failure to thoroughly investigate falls, conduct comprehensive assessments, develop and revise care plans, monitor daily weights, include Black Box Warnings in care plans, monitor blood pressure and blood sugar, attempt psychotropic drug reduction, monitor bowel movements, ensure RN coverage, provide dental services, maintain medication availability, and maintain infection control. Corrective actions and responsible parties are detailed for each deficiency.
Severity Breakdown
D: 6
E: 4
F: 2
C: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate falls | D |
| Failure to conduct comprehensive assessment | E |
| Failure to accurately complete assessments for care plan purposes | D |
| Failure to develop a comprehensive plan of care for dental, constipation, and nutritional needs | D |
| Failure to review and revise care plans to meet residents' individual nutrition needs | D |
| Failure to monitor daily weights as ordered by physician | D |
| Failure to include Black Box Warnings in care plans | E |
| Failure to adequately monitor blood pressure and blood sugar with notification to physician | E |
| Failure to attempt drug reduction on psychotropic medications | E |
| Failure to adequately monitor bowel movements and initiate bowel protocol | E |
| Failure to ensure RN coverage for 8 consecutive hours a day, 7 days a week | F |
| Failure to ensure dental services for all residents | D |
| Failure to ensure availability of medications for administration | D |
| Failure to provide adequate isolation precautions and maintain effective infection control program | F |
| Failure to retain services of a full-time certified dietary manager | C |
Report Facts
Complete Date: Mar 1, 2016
Complete Date: Feb 29, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for overseeing multiple corrective actions including fall investigations, MDS process, care plans, monitoring, infection control, and medication availability | |
| Pharmacist | Responsible for monitoring Black Box Warnings and psychotropic drug reduction | |
| Dietary Manager | Responsible for updating care plans related to dietary changes | |
| Restorative Aide | Responsible for monitoring daily weights | |
| Charge Nurse | Responsible for charting weights, monitoring mouth sores, and medication availability | |
| Social Service Designee | Responsible for monitoring dental appointments and emergency dental care | |
| Administrator | Responsible for overseeing dietary manager course completion | |
| Director of Operation | Responsible for ensuring RN coverage and dietary manager course completion |
Inspection Report
Life Safety
Deficiencies: 1
Feb 19, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited during the Life Safety Code survey at 'F' level severity. | F |
Report Facts
Effective date for denial of payments: May 19, 2016
Provider agreement termination date: Aug 19, 2016
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Annual Inspection
Deficiencies: 1
Feb 1, 2016
Visit Reason
A health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'F' level, indicating significant noncompliance. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions will be imposed.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'F' level | F |
Report Facts
Months until termination recommendation: 6
Denial of Payment effective date: May 1, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter regarding enforcement and plan of correction. |
Inspection Report
Census: 35
Deficiencies: 1
Jan 25, 2016
Visit Reason
The inspection was a licensure survey to assess compliance with dietary services regulations.
Findings
The facility failed to retain the services of a full-time certified dietary manager to oversee the dietary department. The current dietary manager lacked certification but was in training to complete certification by August 2016.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to employ a full-time certified dietary manager to oversee the dietary department. | SS=C |
Report Facts
Census: 35
Inspection Report
Follow-Up
Deficiencies: 2
Nov 19, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.60(a),(b) and 483.65 have been corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 19, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection related to pharmaceutical services and infection control.
Findings
The facility failed to provide timely medication administration and maintain an effective infection control program. Corrective actions include new policies for medication notification and infection tracking to ensure compliance.
Deficiencies (2)
| Description |
|---|
| Failure to provide pharmaceutical services to assure timely medication administration as ordered by the physician. |
| Failure to maintain an infection control program to continually identify infections within the building to prevent the spread of infections. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Olautt | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Oct 20, 2014
Visit Reason
A health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency at level 'F', widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective November 19, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Level 'F' deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the survey findings. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Oct 20, 2014
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation #78844 to assess compliance with pharmaceutical services and infection control requirements.
Findings
The facility failed to provide timely medication administration for one resident, resulting in five missed doses of a prescribed diuretic. Additionally, the facility did not maintain an effective infection control program, lacking ongoing monitoring, tracking, trending of infections, and staff re-education despite a high infection rate.
Complaint Details
The visit was complaint-related as indicated by the health resurvey and complaint investigation #78844. The complaint involved failure to provide timely medication administration and inadequate infection control practices.
Severity Breakdown
Level F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide pharmaceutical services to assure timely medication administration, resulting in missed doses of ordered medication for resident #19. | Level F |
| Failure to maintain an infection control program to identify and prevent the spread of infections, including lack of monitoring, tracking, trending, and staff re-education. | Level F |
Report Facts
Residents present: 36
Residents reviewed for unnecessary medications: 5
Missed medication doses: 5
Residents with infections: 14
Percentage of residents with infections: 29
Residents with urinary tract infections: 5
Inspection Report
Life Safety
Deficiencies: 1
Apr 17, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found at 'E' level, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. | E |
Report Facts
Effective date for denial of payments: Jul 17, 2014
Effective date for provider agreement termination: Oct 17, 2014
IDR request timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 4
Oct 22, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies identified by their regulation numbers and prefix codes have been corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulations 483.20(d)(3) and 483.10(k)(2) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Follow-Up
Deficiencies: 13
Sep 18, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date, 09/18/2013.
Deficiencies (13)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(g) - (j) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(i) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.30(e) |
| Deficiency related to regulation 483.35(c) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 13
Inspection Report
Plan of Correction
Deficiencies: 4
Sep 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection.
Findings
The facility identified failures in housekeeping and maintenance, care plan updates, pressure ulcer monitoring and treatment, and resident supervision to prevent accidents. Corrective actions and responsible staff roles were outlined to address these deficiencies.
Severity Breakdown
E: 3
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide housekeeping and maintenance services to the dining room and beauty shop | E |
| Failure to review and revise care plans to reflect changes in resident status or needs | E |
| Failure to ensure residents receive adequate monitoring with appropriate treatment of pressure ulcers | D |
| Failure to ensure residents receive adequate supervision and assistive devices to prevent accidents | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Olautt | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 4
Sep 18, 2013
Visit Reason
The inspection was conducted as a Non-compliance Revisit and Complaint investigation related to housekeeping, maintenance, care planning, pressure ulcer treatment, and fall prevention.
Findings
The facility failed to provide adequate housekeeping and maintenance services, failed to review and revise care plans consistently for multiple residents, failed to provide adequate treatment and monitoring for pressure ulcers, and failed to ensure adequate supervision and assistive devices to prevent repeated falls for several residents.
Complaint Details
The inspection was triggered by complaints #68126 and #68485, focusing on housekeeping, care planning, pressure ulcer treatment, and fall prevention.
Severity Breakdown
SS=E: 3
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services in the dining room and beauty shop. | SS=E |
| Failed to review and revise the plan of care for 5 of 16 residents reviewed, including inconsistent care plans and failure to implement fall prevention interventions. | SS=E |
| Failed to ensure 3 of 5 residents reviewed for pressure ulcers received adequate monitoring and treatment. | SS=D |
| Failed to ensure 5 of 8 residents reviewed for accidents received adequate supervision and/or assistive devices to prevent repeated falls. | SS=E |
Report Facts
Census: 38
Residents reviewed: 16
Fall risk score: 13
Fall risk score: 22
Fall risk score: 16
Fall risk score: 4
Braden score: 16
Braden score: 13
Pressure ulcer size: 1.5
Pressure ulcer size: 0.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff AA | Maintenance Staff | Reported on housekeeping and maintenance issues in dining room and beauty shop. |
| Staff CC | Housekeeping Staff | Reported cleaning attempts and plans for carpet removal. |
| Staff BB | Administrative Staff | Provided quote for tile replacement in dining area. |
| Staff M | Direct Care Staff | Reported changes in resident #10's care plan and use of pivot pad. |
| Staff O | Direct Care Staff | Reported resident #10 did not use pivot pad as therapy took it. |
| Staff L | Administrative Nursing Staff | Reported on hospice evaluation and care plan changes for resident #7. |
| Staff Z | Licensed Nursing Staff / Wound Care Nurse | Performed wound assessments and reported communication issues. |
| Staff A | Administrative Nursing Staff | Reported lack of awareness of pressure ulcers and communication failures. |
| Staff K | Direct Care Staff | Reported resident complaints of soreness and pressure ulcer awareness. |
| Staff B | Direct Care Staff | Reported on fall safety checks and resident assistance. |
| Staff E | Direct Care Staff | Reported resident fall risk interventions and personal alarm use. |
| Staff F | Direct Care Staff | Reported resident fall risk interventions and personal alarm use. |
| Staff G | Licensed Nursing Staff | Reported on fall training and incident response. |
| Staff J | Direct Care Staff | Reported resident fall risk and interventions. |
| Staff N | Direct Care Staff | Reported resident ambulation preferences and personal alarm use. |
| Staff R | Direct Care Staff | Assisted resident with ambulation and reported on fall safety checks. |
| Staff U | Direct Care Staff | Reported resident need for repositioning and toileting assistance. |
Inspection Report
Plan of Correction
Deficiencies: 18
Aug 25, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior state survey ending July 26, 2013. It outlines corrective actions to address multiple areas of noncompliance identified by the state agency.
Findings
The facility identified multiple deficiencies including failure to investigate and report incidents of neglect, inadequate housekeeping and maintenance, incomplete care area assessments, inaccurate care planning, failure to prevent pressure ulcers, inadequate supervision to prevent accidents, failure to maintain residents' weight, improper medication monitoring, failure to post daily staff schedules, failure to follow planned menus, unsanitary food storage and preparation, failure to monitor drug irregularities, expired medication stock, lack of infection control program, and failure to maintain a quality assurance committee.
Severity Breakdown
D: 6
E: 3
G: 3
C: 1
F: 4
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate and report incidents of alleged neglect for falls and fractures | D |
| Failure to provide housekeeping and maintenance services to various facility areas | E |
| Failure to complete care area assessments (CAAs) with comprehensive assessments | E |
| Failure to accurately complete assessments for care planning purposes | D |
| Failure to develop a comprehensive care plan | D |
| Failure to review and revise care plans to reflect changes in resident status or needs | E |
| Failure to ensure residents do not develop pressure ulcers | G |
| Failure to provide adequate supervision and assistive devices to prevent accidents | G |
| Failure to maintain residents' weight within acceptable parameters | G |
| Failure to ensure residents remain free of unnecessary medications and lack of follow-up on PRN medication | D |
| Failure to ensure daily staff posting includes staff schedule for each shift | C |
| Failure to follow planned menu and recipe to maintain acceptable nutritional values | F |
| Failure to store, prepare, and serve food in a sanitary manner | F |
| Failure of facility pharmacist to identify drug irregularities to ensure residents remain free of unnecessary medications | D |
| Failure to follow-up on PRN medications related to pain | D |
| Failure to monitor for expired stock medication | D |
| Failure to establish and maintain an infection control program | F |
| Failure to maintain a quality assurance committee that develops and implements appropriate corrective actions | F |
Report Facts
Deficiency completion date: Aug 25, 2013
State survey end date: Jul 26, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | Contact person listed for Plan of Correction assistance |
| Olautt | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 14
Jul 26, 2013
Visit Reason
The inspection was a health resurvey and complaint investigation triggered by complaints regarding neglect and falls with fractures among residents.
Findings
The facility failed to thoroughly investigate and report incidents of alleged neglect involving multiple residents with falls and fractures. The facility also failed to maintain adequate care plans, conduct comprehensive assessments, follow up on PRN medications, monitor nutritional status, maintain sanitary conditions, and ensure adequate supervision and assistive devices to prevent accidents.
Complaint Details
The visit was complaint-related involving allegations of neglect, falls with fractures, and inadequate care.
Severity Breakdown
SS=E: 4
SS=D: 5
SS=G: 3
SS=C: 1
SS=F: 2
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate and report alleged neglect involving falls with fractures for multiple residents. | SS=E |
| Failure to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior. | SS=E |
| Failure to complete comprehensive assessments including care area assessments for multiple residents. | SS=E |
| Failure to accurately complete assessments for residents including identification of falls, fractures, and pressure ulcers. | SS=D |
| Failure to develop comprehensive care plans including measurable objectives and timetables for residents with pressure ulcers, weight loss, and discharge planning needs. | SS=D |
| Failure to review and revise care plans to provide adequate supervision and assistive devices to prevent falls and accidents. | SS=D |
| Failure to maintain acceptable nutritional status for a resident with significant weight loss and failure to notify physician or family. | SS=G |
| Failure to ensure residents remain free from unnecessary drugs including lack of follow-up on PRN medications and behavior monitoring. | SS=D |
| Failure to post daily nurse staffing information for all shifts in a clear and accessible manner. | SS=C |
| Failure to follow planned menus and recipes to meet nutritional needs of residents. | SS=G |
| Failure to store and prepare food under sanitary conditions including unlabeled food and unclean kitchen equipment. | SS=G |
| Failure to monitor for expired stock medications including daily medications for a resident. | SS=G |
| Failure to establish and maintain an infection control program to track and prevent infections. | SS=F |
| Failure to maintain an effective quality assurance committee that develops and implements plans of action to correct quality deficiencies. | SS=F |
Report Facts
Resident census: 40
Weight loss: 15
Fall risk score: 14
Fall risk score: 13
Fall risk score: 22
Fall risk score: 14
Medication administrations: 51
Medication administrations: 16
Medication administrations: 14
Medication administrations: 2
Medication administrations: 7
Medication administrations: 1
Weight: 140
Weight: 132
Weight loss percentage: 10.14
Weight loss: 15
Medication expiration date: 2013.04
Medication expiration date: 2013.06
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Administrative nursing staff | Verified failure to investigate and report falls; reported lack of fall/incident log; reported failure to notify physician and family of weight loss; reported failure to maintain quality assurance committee |
| Licensed nursing staff I | Licensed nurse | Reported procedures for neuro checks and fall documentation; reported not placing interventions on care plan; reported lack of awareness of resident weight loss |
| Direct care staff P | Direct care staff | Reported resident ambulation and fall risk; described resident care and transfers |
| Direct care staff W | Direct care staff | Reported resident fall and response; described behavior monitoring |
| Dietary staff F | Dietary staff | Reported no use of recipes for pureed diets; verified menus are resident choice; reported failure to notify physician of weight loss |
| Consultant staff G | Dietary consultant | Reported facility failed to follow planned menus and recipes |
| Licensed staff E | Licensed nurse | Verified resident lacked pressure ulcer on admission; reported wound nurse measures wounds weekly |
| Direct care staff L | Direct care staff | Reported resident fall alarms and care plan |
| Licensed staff D | Licensed nurse | Reported resident fall and care plan interventions |
| Licensed nursing staff J | Licensed nurse | Reported bruise assessment and notification procedures |
| Administrative nursing staff C | Administrative nursing staff | Reported new to position; reported care plans need work; reported difficulty updating care plans |
| Consultant staff KK | Consultant pharmacist | Reported attempts to check MARs for PRN follow-up but not all residents reviewed |
Inspection Report
Follow-Up
Deficiencies: 3
Mar 25, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that deficiencies previously cited under regulations 483.10(b)(11), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.25(h) were corrected by 03/16/2013.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.10(b)(11) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Feb 15, 2013
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation at Winfield Rest Haven.
Findings
The facility failed to notify the physician in a timely manner following accidents, failed to thoroughly investigate and report incidents with injuries to the state agency, and failed to ensure adequate supervision and use of assistive devices to prevent repeated accidents.
Complaint Details
This Plan of Correction is related to a complaint investigation at Winfield Rest Haven.
Severity Breakdown
D: 2
G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the physician in a timely manner following an accident. | D |
| Failure to thoroughly investigate and report incidents with injuries to the state agency. | D |
| Failure to ensure adequate supervision and/or assistive devices to prevent repeated accidents. | G |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Feb 15, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#62925) related to failure to notify the physician timely following resident accidents and failure to investigate and report alleged neglect incidents.
Findings
The facility failed to notify the physician timely after two falls resulting in a fractured hip and elbow for one resident, failed to thoroughly investigate and report these incidents to the state agency, and failed to provide adequate supervision and assistive devices to prevent repeated falls for the resident with dementia and fluctuating physical ability.
Complaint Details
Complaint investigation #62925 focused on failure to notify physician timely after resident falls and failure to investigate and report alleged neglect incidents resulting in fractures.
Severity Breakdown
SS=D: 1
SS=G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify the physician in a timely manner following two falls resulting in a fractured hip and elbow for resident #01. | SS=D |
| Failure to thoroughly investigate and report two incidents of alleged neglect resulting in fractures to the state agency. | SS=G |
| Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistive devices to prevent repeated falls. | SS=G |
Report Facts
Resident census: 39
Falls resulting in injury: 2
Hours delay in physician notification: 12.17
Days delay in state agency reporting: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Administrative Licensed Nurse | Reported delay in physician notification and failure to report fall to state agency |
| Staff H | Licensed Nurse | Worked nights of resident falls and acknowledged failure to notify physician timely |
| Staff R | Direct Care Staff | Reported resident dementia and frequent unassisted getting up leading to falls |
| Staff D | Direct Care Staff | Reported attempts to check resident every 2 hours but resident still fell |
| Staff L | Direct Care Staff | Reported resident frequently got up unassisted causing falls and bruises |
| Staff M | Direct Care Staff | Assisted with resident cares and observed bruising |
| Staff Q | Licensed Nurse | Called to check resident pain, unaware of fall or bruising |
| Staff P | Consultant Staff | Assisted resident with exercises and noted resident pain and difficulty |
Inspection Report
Follow-Up
Deficiencies: 7
May 3, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2012-04-03.
Findings
The report shows that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of 2012-05-03.
Deficiencies (7)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(2)-(5) |
| Deficiency related to regulation 483.20(i) - (j) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 6
May 3, 2012
Visit Reason
This document is a Plan of Correction submitted by Winfield Rest Haven in response to deficiencies cited in a prior inspection report.
Findings
The facility failed to ensure residents' access to funds, verify responsible parties received quarterly notices, maintain Medicaid account balances below limits, complete accurate discharge assessments, develop and revise care plans for fall prevention, pressure ulcers, and sleeping accommodations, provide interventions for pressure ulcers, and maintain appropriate laundry water temperatures.
Severity Breakdown
E: 1
D: 4
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to allow residents access to resident's fund on an ongoing basis | E |
| Failure to complete an accurate comprehensive assessment related to planned discharge | D |
| Failure to develop a plan of care for residents related to fall prevention | D |
| Failure to review and revise care plans for falls, pressure ulcers and sleeping accommodations | D |
| Failure to provide intervention to reduce pressure ulcers and failure to change dressings as ordered | D |
| Failure to ensure appropriate water temperatures in the laundry are maintained | F |
Report Facts
Medicaid account balance limit: 1800
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Olautt Administrator | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Modified the Plan of Correction |
Inspection Report
Routine
Census: 39
Deficiencies: 7
Apr 3, 2012
Visit Reason
The inspection was a routine health resurvey to assess compliance with health and safety regulations.
Findings
The facility was found deficient in multiple areas including management of residents' personal funds, accuracy and revision of resident assessments and care plans, prevention and treatment of pressure ulcers, fall prevention and supervision, and infection control related to laundry water temperatures.
Severity Breakdown
SS=E: 1
SS=D: 5
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to handle residents' personal funds according to acceptable accounting principles including lack of consents, failure to provide access, and failure to notify Medicaid residents of account balances. | SS=E |
| Failed to complete an accurate comprehensive assessment for a resident related to planned discharge. | SS=D |
| Failed to develop comprehensive care plans for residents related to fall prevention. | SS=D |
| Failed to review and revise residents' care plans including for falls, pressure ulcers, and sleeping accommodations. | SS=D |
| Failed to provide necessary treatment and services to prevent and promote healing of pressure ulcers including failure to provide pressure relief devices and timely dressing changes. | SS=D |
| Failed to ensure resident environment was free of accident hazards and provide adequate supervision and assistive devices to prevent accidents and falls. | SS=D |
| Failed to ensure appropriate water temperatures in laundry for sanitation during a time of resident respiratory infections and influenza cases. | SS=F |
Report Facts
Census: 39
Residents with personal funds handled: 18
Medicaid residents with funds handled: 12
Resident #42 fund balance: 2008.6
Resident #42 current balance: 2639.45
Falls for resident #43: 4
Water temperature: 168
Water temperature: 162
Inspection Report
Plan of Correction
Deficiencies: 1
N018007 POC 25ML11
Visit Reason
This document is a Plan of Correction submitted by Winfield Rest Haven in response to deficiencies identified in a prior inspection related to PBJ (Payroll-Based Journal) time tracking.
Findings
The administrator has been notified of PBJ audit results and has implemented use of the PBJ time reading system to record on-site hours, ensuring 40 plus hours each week on-site as required.
Deficiencies (1)
| Description |
|---|
| Failure to properly record administrator's on-site hours using the PBJ time reading system prior to January 12, 2020. |
Report Facts
Complete Date for F0000: 2020
Complete Date for F851: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Named as the administrator implementing corrective action for PBJ time tracking |
Inspection Report
Plan of Correction
Deficiencies: 3
N018007 POC 2TZY11
Visit Reason
This document is a Plan of Correction submitted by Winfield Rest Haven in response to deficiencies cited in a prior inspection report dated 09/29/2017.
Findings
The plan outlines corrective actions for deficiencies related to coordination of care with an outside dialysis center, replacement and monitoring of wheelchair cushions, and updating policies and procedures for fall and head injury prevention including enhanced risk assessment meetings and nursing staff assignments.
Severity Breakdown
D: 2
G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Coordination of care agreement/arrangement contract with outside dialysis center not properly located. | D |
| Wheelchair cushions need replacement and monitoring policy implementation. | D |
| Policy and procedure for fall and head injury prevention require updating and implementation of risk assessment meetings and nursing monitoring. | G |
Report Facts
Deficiency completion dates: Oct 6, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
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