Inspection Reports for
Winfield Rest Haven II Lc

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.

The visit was triggered by complaints 190978 and 190727, focusing on assessment accuracy, care planning, accident prevention, medication monitoring, and infection control.

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.

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.

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.

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.

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.

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.

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.

The COVID-19 survey was deficiency free, indicating no deficiencies were found during the inspection.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection included complaint investigations #147834 and #144736.

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.

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.

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.

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.

This Plan of Correction is related to the Winfield West Haven complaint dated 06/06/2018.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

All previously cited deficiencies listed with their regulation numbers were marked as completed with corrective actions accomplished by 03/01/2016.

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.

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.

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.

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.

The report confirms that deficiencies previously cited under regulations 483.60(a),(b) and 483.65 have been corrected as of the revisit date.

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.

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.

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.

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.

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.

The report confirms that all previously cited deficiencies identified by their regulation numbers and prefix codes have been corrected as of the revisit date.

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.

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.

The inspection was triggered by complaints #68126 and #68485, focusing on housekeeping, care planning, pressure ulcer treatment, and fall prevention.

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.

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.

The visit was complaint-related involving allegations of neglect, falls with fractures, and inadequate care.

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.

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.

This Plan of Correction is related to a complaint investigation at Winfield Rest Haven.

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 investigation #62925 focused on failure to notify physician timely after resident falls and failure to investigate and report alleged neglect incidents resulting in fractures.

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.

The report shows that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of 2012-05-03.

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.

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.

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.

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.