Inspection Reports for
Winfield Rest Haven II Lc
1611 RITCHIE ST, WINFIELD, KS, 67156-5252
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
16.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
182% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
98% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 27, 2025
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 12/04/24.
Findings
All deficiencies 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.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 5
Date: Dec 4, 2024
Visit Reason
The inspection was a Health Resurvey and investigation of complaints 190978 and 190727 at Winfield Rest Haven II, LLC.
Complaint Details
The inspection was triggered by complaints 190978 and 190727. The findings include substantiated issues with assessment accuracy, care plan revisions, accident prevention, psychotropic medication monitoring, and infection control.
Findings
The facility failed to ensure accuracy of resident assessments, timely care plan revisions, proper use of safety devices, appropriate monitoring of psychotropic medication, and adherence to infection prevention protocols including enhanced barrier precautions.
Deficiencies (5)
F641 Accuracy of Assessments: The facility failed to ensure the accuracy of Minimum Data Set assessments for two residents regarding impairment and restraint use.
F657 Care Plan Timing and Revision: The facility failed to review and revise care plans for two residents to include enhanced barrier precautions related to catheters and nephrostomy tubes.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure a resident was secured with a safety belt in the whirlpool bath chair, resulting in a fall and forehead laceration requiring sutures.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to complete required AIMS assessments for a resident receiving antipsychotic medication.
F880 Infection Prevention & Control: The facility failed to ensure staff donned appropriate PPE for residents on enhanced barrier precautions, risking cross contamination and infection spread.
Report Facts
Resident census: 40
Residents reviewed: 14
Sutures required: 8
Fall risk score: 13
BIMS score: 5
BIMS score: 14
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed inaccurate MDS coding and expectations for safety belt use and psychotropic 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 and confirmed findings | |
| Certified Nurse Aide P | Observed not wearing isolation gown during catheter care | |
| Certified Nurse Aide MM | Reported not consistently using whirlpool bath chair safety belt prior to resident fall | |
| Consulting Staff GG | Completed MDS assessments and confirmed care plan revision expectations |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Dec 4, 2024
Visit Reason
The inspection was conducted following complaints regarding resident safety and infection control practices at the nursing home.
Complaint Details
The investigation was complaint-driven, focusing on a fall incident involving Resident 35 and infection control breaches involving Residents 23, 26, and 29. The fall was substantiated with actual harm. Infection control breaches were noted with minimal harm or potential for harm.
Findings
The facility failed to ensure staff secured a resident in a whirlpool bath chair, resulting in a fall with injury. Additionally, staff did not consistently use appropriate personal protective equipment (PPE) during high contact care activities, risking infection spread.
Deficiencies (2)
F 0689: The facility failed to ensure staff used the safety belt for Resident 35 during transfer out of the whirlpool bath chair, resulting in a fall with a forehead laceration requiring eight sutures.
F 0880: The facility failed to ensure staff donned appropriate PPE for three residents on enhanced barrier precautions, risking the spread of infection.
Report Facts
Residents present: 40
Residents selected for review: 14
Sutures required: 8
Fall Risk Evaluation score: 13
Residents on enhanced barrier precautions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA MM | Certified Nurse Aide | Named in failure to apply safety belt during whirlpool bath transfer causing resident fall |
| Administrative Nurse D | Administrative Nurse | Confirmed expectations for safety belt use and PPE compliance |
| Administrative Staff A | Administrative Staff | Provided instruction on safe bathing practice and safety belt use |
| Licensed Nurse G | Licensed Nurse | Observed failing to don gown during high contact care activities |
| Administrative Nurse E | Administrative Nurse | Failed to apply required PPE during catheter care for Resident 26 |
| CNA P | Certified Nurse Aide | Handled catheter care without required PPE for Resident 26 |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 5
Date: Dec 4, 2024
Visit Reason
The inspection was conducted as an annual survey with a sample of 14 residents reviewed for compliance with care planning, assessment accuracy, accident prevention, medication monitoring, infection control, and other regulatory requirements.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, failed to review and revise care plans for enhanced barrier precautions for two residents, failed to ensure safety belt use during whirlpool bath transfers resulting in a fall and injury, failed to complete required AIMS assessments for antipsychotic medication monitoring, and failed to ensure staff used appropriate enhanced barrier precautions (EBP) including PPE to prevent infection spread.
Deficiencies (5)
F0641: The facility failed to ensure accurate MDS assessments for two residents, including incorrect coding of positioning rails as restraints and failure to assess impairment in extremities.
F0657: The facility failed to review and revise care plans for two residents to include enhanced barrier precautions related to catheters and nephrostomy tubes.
F0689: The facility failed to ensure staff used safety belts during whirlpool bath transfers, resulting in a resident fall with a forehead laceration requiring eight sutures.
F0758: The facility failed to complete required Abnormal Involuntary Movement Scale (AIMS) assessments for a resident receiving antipsychotic medication.
F0880: The facility failed to ensure staff donned appropriate PPE for three residents on enhanced barrier precautions to prevent infection spread.
Report Facts
Residents selected for review: 14
Resident census: 40
Safety belt incident date: 1
Sutures required: 8
AIMS assessments completed: 1
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Dec 4, 2024
Visit Reason
This document is a Plan of Correction submitted by Winfield Rest Haven in response to deficiencies cited during a prior inspection on 12/04/2024.
Findings
The plan addresses multiple deficiencies including inaccurate MDS assessments, incomplete care plans for Enhanced Barrier Precautions and PPE use, safety issues related to whirlpool bath chair use, and psychotropic medication monitoring. The facility outlines corrective actions, staff re-education, audits, and timelines for achieving substantial compliance.
Deficiencies (5)
F641-D: Resident #12’s side rail assessment was revised and MDS corrected; Admission MDS for Resident #35 was inaccurately coded and subsequent assessments were reviewed for accuracy.
F657-D: Care plans for Residents #26 and #30 were revised to include Enhanced Barrier Precautions and proper PPE use; facility-wide review and staff re-education conducted.
F689-G: Resident #35 was sent to the emergency room after an incident involving the whirlpool bath chair; staff re-educated on bath safety and policy revised to include safety instructions.
F758-D: Completed AIMS assessment for Resident #35; reviewed all residents on psychotropic medications for compliance; staff re-educated on medication monitoring and AIMS assessment requirements.
F880-D: Reviewed and revised care practices for Residents #26, #23, and #29 to ensure compliance with Enhanced Barrier Precautions; facility-wide review and staff re-education conducted; audits planned to ensure compliance.
Report Facts
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sydney | Named in relation to MDS assessment deficiency | |
| Melissa Parmley | Administrator | Submitted the Plan of Correction |
| Jessica Patterson | Added Plan of Correction | |
| Lori Mouak | Modified Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-02-15.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2023-03-02, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Feb 15, 2023
Visit Reason
The document is a plan of correction submitted in response to deficiencies cited during an inspection at Winfield Rest Haven on February 15, 2023.
Findings
The facility identified multiple deficiencies including failure to properly implement standing orders for oxygen, incomplete hospice service orders, failure to follow residents' fall interventions, and improper storage of supplies. Corrective actions and staff education were planned and implemented to address these issues.
Deficiencies (5)
F580-D: The facility failed to properly implement standing orders for oxygen and notify physicians of changes in condition. Licensed nurses were educated and audits will be conducted to ensure compliance.
F684-D: The facility failed to ensure all hospice residents had orders for hospice care in their medical records. Audits and staff education were planned to prevent recurrence.
F689-D: Direct care staff did not consistently follow residents' fall interventions as care planned. Staff education and reminders were implemented to improve compliance.
F695-D: The facility again failed to properly implement standing orders for oxygen and notify physicians. Education and audits were planned to ensure adherence to policies.
F921-E: Supplies were improperly stored on the floor and broken vinyl was present. Storage was corrected, staff educated, and environmental services will monitor compliance.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 5
Date: Feb 15, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in several areas including failure to notify a physician of a resident's change in condition requiring oxygen, lack of hospice care orders 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 for a resident requiring it, and failure to maintain a safe and sanitary environment due to improper storage of supplies on the floor.
Deficiencies (5)
F 0580: The facility failed to notify the physician of a change in condition for one resident regarding the need for oxygen implementation.
F 0684: The facility failed to ensure a resident's medical record contained an order for hospice care following admission.
F 0689: The facility failed to follow fall interventions, resulting in a non-injury fall for one resident with a history of falls.
F 0695: The facility failed to obtain an order for oxygen for one resident who required as needed oxygen usage.
F 0921: The facility failed to provide a safe and sanitary environment by storing supplies directly on the floor in multiple areas.
Report Facts
Resident census: 36
Residents sampled: 14
Fall assessments: 6
Boxes of face shields: 1
Boxes of disposable isolation 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 physician |
| Administrative Staff A | Administrative Staff | Confirmed oxygen order had not been initiated and physician was not notified |
| Certified Medication Aide S | Certified Medication Aide | Stated resident received hospice care and staff were not to leave resident unattended in wheelchair |
| Certified Nurse Aide N | Certified Nurse Aide | Stated resident received hospice care and staff were to transfer resident to bed or recliner 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 supplies stored directly on floor during environmental tour |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 5
Date: Feb 15, 2023
Visit Reason
This was a health resurvey inspection to verify compliance with previously cited deficiencies and assess the facility's adherence to regulatory requirements.
Findings
The facility failed to notify a physician of a resident's change in condition requiring oxygen, failed to have an order for hospice care for a resident receiving hospice services, failed to follow fall prevention interventions resulting in a non-injury fall, failed to obtain an order for oxygen for a resident requiring PRN oxygen, and failed to provide a safe and sanitary environment due to storage of supplies directly on the floor.
Deficiencies (5)
F580: The facility failed to notify the physician of a resident's change in condition requiring oxygen initiation.
F684: The facility failed to ensure a resident's medical record contained an order for hospice care following admission.
F689: The facility failed to follow fall interventions, resulting in a non-injury fall for a resident with a history of falls.
F695: The facility failed to obtain an order for oxygen for a resident requiring PRN oxygen usage.
F921: The facility failed to provide a safe and sanitary environment by storing supplies directly on the floor in multiple areas.
Report Facts
Resident census: 36
Residents sampled: 14
Boxes of face shields: 1
Boxes of disposable isolation gowns: 2
Cases of soda: 3
12-pack of soda: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/25/2021.
Findings
All deficiencies cited in the prior inspection have been corrected as of 09/24/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Census: 20
Deficiencies: 1
Date: Aug 25, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with requirements related to notification of Medicare/Medicaid coverage termination and potential liability for non-covered services.
Findings
The facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to residents whose Medicare Part A services ended. Additionally, the facility failed to submit claims or appeals to Medicare as requested by residents.
Deficiencies (1)
F 0582: The facility failed to provide the NOMNC when all covered services ended for coverage reasons and failed to issue SNFABN in a timely manner for residents 18, 71, and 72. The facility also failed to submit a claim or appeal to Medicare A upon request of resident 71.
Report Facts
Census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative A | Verified discrepancies related to Advanced Beneficiary Notices and demand submission |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 25, 2021
Visit Reason
The document is a plan of correction responding to deficiencies cited in a prior inspection related to Medicare Part A beneficiary notices and billing procedures.
Findings
Deficiencies were found in the process of issuing Skilled Nursing Facility advanced beneficiary notices and Notice of Medicare Non Coverage to residents coming off Medicare Part A stays. The facility lacked proper notification and billing procedures for beneficiaries with remaining benefit days.
Deficiencies (1)
F582-D: The facility failed to properly issue advanced beneficiary notices and Notice of Medicare Non Coverage to residents coming off Medicare Part A with remaining benefit days. Notices were not consistently given at least two days prior to the last day of Medicare coverage, and documentation of beneficiary notification and appeals was inadequate.
Inspection Report
Re-Inspection
Census: 20
Deficiencies: 1
Date: Aug 25, 2021
Visit Reason
The visit was a health resurvey to assess compliance with Medicaid/Medicare coverage and liability notice requirements.
Findings
The facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to residents when Medicare Part A services ended. Additionally, the facility did not submit claims or appeals to Medicare as requested by residents.
Deficiencies (1)
F 582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide the NOMNC when all covered services ended for coverage reasons and failed to issue SNFABN in a timely manner for residents R18, R71, and R72. The facility also failed to submit a claim or appeal to Medicare A upon request of resident R71.
Report Facts
Resident 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 appeals |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 26, 2021
Visit Reason
An offsite revisit was conducted to verify correction of 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.
Inspection Report
Abbreviated Survey
Census: 22
Deficiencies: 3
Date: Nov 17, 2020
Visit Reason
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.
Deficiencies (3)
F868 Quality assessment and assurance committee failed to meet at least quarterly and as needed to identify quality issues and develop corrective actions.
F881 The facility failed to consistently utilize an antibiotic stewardship program that included tracking and monitoring of antibiotic use for residents.
F882 The facility failed to designate an infection preventionist who was qualified and had completed specialized training in infection prevention and control.
Report Facts
Resident census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed and provided information regarding QA meetings, infection control logs, and infection preventionist role. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: 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 facility planned corrective actions including holding QAPI/QAA meetings, adherence to the Antibiotic Stewardship program with initiation of logs, and completion of CDC Infection Prevention and Control training by the Director of Nursing.
Deficiencies (4)
F0000: The statement of deficiencies will be taken to the facility's Quality Assurance/Assessment Committee on 12/29/2020.
F868: Facility to hold QAPI/QAA meeting on 12/29/2020 and quarterly thereafter.
F881: Facility to adhere to the Antibiotic Stewardship program. October and November logs will be initiated with completion by 12/29/2020. Infection Control Preventionist will present the data at the QAPI meeting on 12/29/2020.
F882: Director of Nursing completed the CDC Train Infection Prevention and Control Program on 11/22/2020 and is now the Certified Infection Control Preventionist.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amie Chandler | RN DON | Submitted the Plan of Correction. |
| Janice VanGotten | Added and modified the Plan of Correction. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 25, 2020
Visit Reason
A non-compliance revisit was conducted to verify correction of all previous deficiencies cited on 2020-06-22.
Findings
All deficiencies cited in the prior inspection were corrected by the compliance date of 2020-07-22. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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 with no cited deficiencies.
Deficiencies (1)
F0000 Deficiency Free Covid 19 survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 25, 2020
Visit Reason
A targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with COVID-19 related infection control practices.
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: 2
Date: 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 on policies and procedures, and ongoing surveillance by department heads and supervisors to ensure corrections are sustained.
Deficiencies (2)
F0000: Masks are always to be worn by residents when staff is providing care, including when staff enter occupied rooms for various tasks. Staff will encourage mask use or tissue covering if residents refuse to wear masks.
F880-F: Corrective actions include placing reminder signs, providing staff signature pages, and attaching command strips for mask storage. Surveillance will continue for three months to ensure compliance and provide additional training.
Report Facts
Plan of Correction completion date: Jul 24, 2020
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 1
Date: Jun 22, 2020
Visit Reason
A Targeted Infection Control/COVID-19 Survey was conducted to assess compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility failed to provide face masks to four residents prior to staff providing direct care, increasing the risk of COVID-19 transmission. Observations and staff interviews confirmed residents were not masked during care as required by facility policy.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to provide face masks to four residents prior to direct care, increasing the risk of COVID-19 transmission to all residents.
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 |
| CNA S | Certified Nurse Aide | Observed assisting residents without masks |
| CNA O | Certified Nurse Aide | Reported staff must place masks on residents during care |
| Administrative Nurse C | Administrative Nurse | Reported residents remain in rooms when quarantined and staff should wear masks |
| Licensed Nurse G | Licensed Nurse | Reported all residents should wear masks during care |
| Administrative Nurse B | Administrative Nurse | Expected staff to place masks on residents prior to care |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 28, 2020
Visit Reason
An offsite revisit was conducted to verify correction of 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
Date: May 14, 2020
Visit Reason
An offsite revisit was conducted to verify correction of 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.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 12, 2020
Visit Reason
This document is a Plan of Correction submitted in response to citation findings from a Health Resurvey conducted on 02/12/2020.
Findings
The plan addresses issues related to abuse and neglect policies, employee disciplinary actions, and resident assessments following an incident involving alleged perpetrator information and police notification.
Deficiencies (2)
F0000: The facility provided a signature sheet covering the abuse and neglect policy and submitted alleged perpetrator information related to the incident. The Winfield Police Department was notified with case number W20-01113.
F600-D: Corrective actions included termination of an employee, suspension of a nurse, and completion of a skin assessment on a resident not cognitively intact. Monitoring plans include reporting unusual occurrences and conducting investigations with interviews and video monitoring.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carmen Carothers | Terminated on 2/7/2020 related to the incident. | |
| Thea Kilpatric | RN | Suspended on 2/10/2020 and had not worked since 2/6/2020. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Feb 12, 2020
Visit Reason
The inspection was conducted as a complaint investigation (#150147) regarding allegations of abuse at the facility.
Complaint Details
Complaint investigation #150147 substantiated physical abuse by a certified nurse aide against one resident. The resident was cognitively impaired and dependent. The staff member was terminated, police and state hotline were notified, and retraining was initiated.
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 foot, causing the wheelchair to turn 90 degrees. The resident did not sustain injury, and the staff member was terminated following the investigation.
Deficiencies (1)
F 600: The facility failed to prevent physical abuse to a cognitively impaired resident when a certified nurse aide pushed an ice chest cart into the resident's wheelchair and right foot, causing the wheelchair to turn 90 degrees.
Report Facts
Resident census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named as the staff member who committed physical abuse by pushing the resident's wheelchair with an ice chest cart |
| Administrative Nurse B | Administrative Nurse | Conducted investigation and verified actions taken including termination of CNA D |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 3, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-12-12.
Findings
All deficiencies have been corrected as of the compliance date of 2020-01-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Feb 2, 2020
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that the facility was not accurately reporting the licensed administrator's hours on the Payroll Based Journal (PBJ).
Complaint Details
The complaint investigation KS000149571 alleged inaccurate reporting of the licensed administrator's hours on the PBJ. The allegation was substantiated by audit findings and staff interviews.
Findings
The facility failed to submit complete and accurate staffing information to the federal regulatory agency through PBJ, reporting the licensed administrator worked 40 hours per week onsite when he was not physically present in the building for those hours.
Deficiencies (1)
F851 Payroll Based Journal requirement was not met as the facility reported the licensed administrator worked 40 hours per week onsite but he was not physically present in the building during those hours.
Report Facts
Resident census: 35
Audit sample size: 9
Reported hours: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Licensed Administrator | Named in the finding for inaccurate reporting of hours worked onsite on PBJ. |
| Administrative Nurse E | Administrative Nurse | Provided interview details about Staff A's attendance and concerns about falsification of hours. |
| Administrative Assistant Staff Y | Administrative Assistant | Entered Staff A's hours into the time system as instructed. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Dec 12, 2019
Visit Reason
This document is a Plan of Correction responding to citation findings from the Health Resurvey conducted on December 12, 2019.
Findings
The plan addresses deficiencies related to comprehensive care plans, dialysis policies, drug regimen reviews, medication administration, and medication error prevention. Corrective actions include policy updates, staff education, and new consulting pharmacist involvement.
Deficiencies (6)
F0000: Plan of Corrections for citation findings from the Health Resurvey conducted on 12/12/2019. Policies will be presented and implemented by January 17, 2020, with staff education ongoing.
F656: Comprehensive care plan policy updated to include hemodialysis procedures. Staff educated and care plans updated accordingly.
F657: New hemodialysis policy written and staff educated. Medical Director to provide vital sign parameters and nurses to notify if out of range.
F756: New consulting pharmacist began 01/01/2020 and reviewed drug regimen policy with staff.
F757: Medication aides to take vital signs twice daily and report abnormalities immediately. Parameters placed on medication carts and staff educated.
F760: All medication aides and licensed nurses to review medication administration policy. Consulting pharmacist to review medications monthly and report errors to DON.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 5
Date: 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.
Complaint Details
The inspection was triggered by complaint investigations #147834 and #144736.
Findings
The facility failed to develop a comprehensive care plan for dialysis assessments before and after dialysis for one resident. The facility also failed to monitor the dialysis shunt and blood pressure after dialysis, failed to identify irregularities in insulin administration by the consulting pharmacist, failed to ensure one resident remained free of unnecessary medications due to inadequate monitoring of blood pressure with diuretic use, and failed to prevent significant medication errors related to insulin administration outside physician-ordered parameters.
Deficiencies (5)
F656: The facility failed to develop a comprehensive care plan for dialysis assessments before and after dialysis for one resident.
F698: The facility failed to monitor the dialysis shunt and blood pressure upon return from dialysis for one resident.
F756: The consulting pharmacist failed to identify irregularities in insulin administration when staff administered insulin outside physician-ordered blood sugar parameters for one resident.
F757: The facility failed to ensure one resident remained free of unnecessary medications due to inadequate monitoring and physician notification of blood pressures with diuretic use.
F760: The facility failed to prevent significant medication errors by administering insulin when the resident's blood sugar was below physician-ordered parameters.
Report Facts
Resident census: 33
Residents reviewed: 14
Dialysis frequency: 3
Insulin administrations outside parameters: 100
Blood pressure readings outside parameters: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Confirmed failure to assess dialysis fistula and vital signs after dialysis; confirmed insulin administration errors. |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding dialysis assessments, medication errors, and pharmacist reviews. |
| Consultant Pharmacy Staff GG | Consultant Pharmacist | Acknowledged delayed identification of insulin administration irregularities. |
| Licensed Nurse G | Licensed Nurse | Confirmed insulin should not have been administered when blood sugar was under 300. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 11, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-12-12.
Findings
All deficiencies have been corrected as of the compliance date of 2019-01-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Dec 12, 2018
Visit Reason
This document is a Plan of Correction submitted in response to citation findings from a health resurvey conducted on December 12, 2018.
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.
Deficiencies (9)
F582 SS=E Policy written for Medicare Denial Notices on 12-24-2018. Social Worker consultant will review ABNs monthly and the SSD position is open for hire.
F636 SS=D Policy regarding comprehensive and quarterly assessments presented to staff. Training new LPN on completing MDS and timeliness.
F638 SS=D Provided policy regarding comprehensive and quarterly assessment to staff. Training new LPN on MDS completion and timeliness.
F641 SS=D Director of Nursing and Assistant Director of Nursing to review data entered into MDS to ensure accuracy.
F656 SS=D Activity Director adopted new Activities/Preferences Comprehensive Assessment form to be completed upon admission and filed appropriately.
F679 SS=D Activity Director to follow the Activities/Preferences Comprehensive Assessment within 48 hours of admission and provided resident with hearing and vision aids.
F756 SS=D Policy written for Drug Regimen Review on 12-24-2018. DON/ADON to monitor weights and blood glucose results and notify physician as ordered.
F757 SS=D Policy written for Drug Regimen Review on 12-24-2018. DON/ADON to monitor weights and blood glucose results and notify physician as ordered.
F812 SS=F Three cutting boards and new rubber spatulas ordered and received in December 2018. Inspection of utensils added to weekly chore list.
Report Facts
Plan of Correction completion date: Jan 11, 2019
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 8
Date: Dec 12, 2018
Visit Reason
The inspection was a health resurvey to evaluate compliance with Medicare/Medicaid regulations and assess the facility's corrective actions.
Findings
The facility failed to provide appropriate beneficiary notices to Medicare residents, complete timely and accurate comprehensive and quarterly assessments, develop individualized care plans including activities, monitor residents' weights and blood glucose levels as ordered, and maintain sanitary food service conditions in the kitchen.
Deficiencies (8)
F582: The facility failed to provide appropriate beneficiary notices to six sampled Medicare residents, denying them rights related to financial liability and appeal of Medicare service denials.
F636: The facility failed to complete a comprehensive assessment within 14 days of admission for one resident and failed to complete a quarterly assessment within required timeframes for another resident.
F641: The facility failed to complete accurate comprehensive and quarterly assessments for one resident, including failure to document significant weight loss.
F656: The facility failed to develop a comprehensive care plan including individualized activity interventions for one resident.
F679: The facility failed to provide an individualized activity program to maintain the physical, mental, and psychosocial well-being of one resident.
F756: The facility failed to monitor daily weights and notify the physician for weight gains over 2 pounds in 24 hours for one resident with heart failure, and failed to notify the physician of blood glucose levels outside ordered parameters for another resident with diabetes.
F757: The facility failed to ensure no unnecessary medications for two residents due to failure to monitor and report weight and blood glucose irregularities to the physician as ordered.
F812: The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen, including use of damaged cutting boards and spatulas and dirty shelving storing mixed items.
Report Facts
Resident census: 38
Residents sampled for review: 13
Residents sampled for beneficiary notice review: 6
Weight gain incidents over 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
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 12, 2018
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a Level F deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2019-01-11.
Deficiencies (1)
A Level F deficiency was cited, indicating widespread noncompliance with potential for more than minimal harm but no immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure & Certification Enforcement Manager | Signed the letter regarding the plan of correction and compliance status. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 29, 2018
Visit Reason
An off-site survey was conducted to verify correction of a previously cited deficiency from 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
Date: Jun 13, 2018
Visit Reason
A complaint survey was conducted on 2018-06-13 for complaint #KS00130312.
Complaint Details
Complaint #KS00130312 was investigated and found to be unsubstantiated.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 13, 2018
Visit Reason
A complaint survey was conducted on 6/13/18 for complaint #KS00130312.
Complaint Details
Complaint #KS00130312 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: 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.
Complaint Details
This Plan of Correction is related to the complaint investigation at Winfield West Haven dated 06/11/2018.
Findings
The plan addresses deficiencies related to abuse, neglect, exploitation, resident rights, and medication administration including controlled substances and PRN medications.
Deficiencies (4)
F0000 statement of deficiencies will be taken to the Quality Assurance Meeting.
F602-E Abuse, Neglect, and Exploitation and Resident Rights in-service was held on 06/11/2018 with sign-in sheet provided.
Medication Administration, Controlled Substances, and PRN medication administration were reviewed with Certified Medication Aides and licensed nurses with sign-in sheet provided.
Policies and education were provided to staff regarding proper protocol in administering PRN Narcotics, with ongoing review by Director of Nursing and Medical Director at QA meetings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Date: Jun 6, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#130130) related to allegations of medication exploitation and errors at the facility.
Complaint Details
Complaint investigation #130130 focused on medication exploitation and errors. The complaint was substantiated by findings of medication staff signing out narcotics but not administering them to residents.
Findings
The facility failed to ensure four residents were free from exploitation of narcotic medications, with 20 tablets signed out but not administered. Medication staff errors included failure to document administration, failure to obtain required vital signs before medication, and untimely medication delivery.
Deficiencies (1)
CFR 483.12: The facility failed to ensure four residents were free from exploitation of narcotic medications, with 20 tablets signed out but not administered as documented in medication administration records.
Report Facts
Resident census: 39
Narcotic tablets exploited: 20
Percocet tablets not administered: 12
Percocet tablets signed out: 14
Hydrocodone-Acetaminophen tablets not administered: 4
Norco tablets signed out: 3
Norco tablets signed out: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse R | Explained medication pass audit and suspended medication staff E due to errors | |
| Licensed nurse B | Verified investigation of possible medication error for resident #5 | |
| Medication staff E | Certified medication aide who signed out narcotic medications but failed to administer them |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 a single '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.
Deficiencies (1)
The facility was cited with an 'E' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: 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 supervision to prevent resident elopement.
Complaint Details
The complaint investigation #129472 found the facility failed to prevent a resident with severe cognitive impairment from eloping. The resident was found two blocks away after wandering outside the facility. The facility was cited for inadequate supervision and care planning.
Findings
The facility failed to develop a baseline care plan with interventions to prevent elopement for one resident and failed to provide adequate supervision and assistive devices to prevent the resident from leaving the facility unnoticed. The resident eloped from the facility, wandering outside and crossing streets before being found and returned safely. The facility was cited for past noncompliance and took corrective actions including one-to-one supervision and policy updates.
Deficiencies (2)
F 655: The facility failed to develop a baseline care plan for one resident that included interventions or instructions to prevent elopement from the facility without staff knowledge.
F 689: The facility failed to provide adequate supervision and/or assistive devices to prevent one resident from leaving the facility without staff knowledge, placing the resident in immediate jeopardy.
Report Facts
Resident census: 36
BIMS score: 6
Wandering risk score: 9
Temperature: 90
Speed limit: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff D | Reported working during 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
Plan of Correction
Deficiencies: 3
Date: May 16, 2018
Visit Reason
This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified in a prior inspection.
Findings
The plan addresses past noncompliance issues identified under tags F0000, F655-D, and F689-J. No new deficiencies or corrective actions requiring plans were noted as all were past noncompliance with no POC required.
Deficiencies (3)
F0000 past noncompliance: No plan of correction required.
F655-D past noncompliance: No plan of correction required.
F689-J past noncompliance: No plan of correction required.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 6, 2018
Visit Reason
A second revisit survey was conducted on 2/5-6/18 to verify correction of all previous deficiencies cited on 9/29/17.
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
Re-Inspection
Deficiencies: 0
Date: Feb 6, 2018
Visit Reason
A second revisit survey was conducted to verify correction of all previous deficiencies cited on 11/30/17.
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Edwards | Named in relation to the revisit survey and deficiency correction |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Nov 30, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the Correct Winfield Rest Haven revisit 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.
Deficiencies (8)
F-Tag 157 The Director of Nursing will review progress notes every morning Monday through Friday to ensure resident family notification of changes and updates.
F-Tag 225 A new policy has been written regarding assessing falls and their causes, with fall investigation reports completed and reviewed by nursing leadership.
F-Tag 279 A new policy has been written on developing baseline and comprehensive care plans with department heads notified and documentation of completion.
F-Tag 280 A new policy has been written on revising care plans with department heads notified and documentation of completion.
F-Tag 314 Policies regarding pressure ulcers were provided and education given to direct care staff with documentation of staff acknowledgment.
F-Tag 323 A new policy on investigating and reporting accidents and incidents was implemented with staff education and acknowledgment.
F-Tag 328 A policy on special needs including vital signs and oxygen application was provided with staff education and acknowledgment.
F-Tag 356 A new daily staffing sheet was created and implemented with policy and staff acknowledgment.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 8
Date: Nov 30, 2017
Visit Reason
The inspection was a non-compliance revisit and complaint investigation related to allegations of neglect, pressure ulcer development, and failure to notify family and thoroughly investigate incidents.
Complaint Details
The complaint investigation involved allegations of neglect, failure to notify family of pressure ulcers, inadequate investigation of falls, failure to follow care plans, and improper oxygen administration.
Findings
The facility failed to notify a resident's family of pressure ulcer development, failed to thoroughly investigate neglect allegations related to falls, failed to update care plans after incidents, failed to provide care to prevent and treat pressure ulcers, failed to administer oxygen as ordered, and failed to post accurate nurse staffing data.
Deficiencies (8)
F157: The facility failed to notify the responsible person of a resident's pressure ulcer development and failed to monitor wounds prior to hospitalization.
F225: The facility failed to thoroughly investigate allegations of neglect related to falls for two residents and failed to implement fall prevention interventions.
F279: The facility failed to develop and implement a care plan for oxygen therapy for a resident upon return from the hospital.
F280: The facility failed to review and revise care plans for two residents related to falls and pressure ulcers, and failed to reposition a resident every 2 hours as required.
F314: The facility failed to provide care and services to prevent pressure ulcers for two residents and failed to provide care and services to heal a pressure ulcer for one resident.
F323: The facility failed to provide adequate supervision and assistive devices to prevent further falls for two residents.
F328: The facility failed to ensure a resident received oxygen per physician orders and failed to discontinue oxygen only after physician approval.
F356: The facility failed to post nurse staffing data daily and failed to update postings with actual hours worked by staff.
Report Facts
Resident census: 37
Fall risk score: 75
Pressure ulcer size: 4
Pressure ulcer size: 2
Oxygen flow rate: 0.5
Oxygen flow rate: 2
Oxygen flow rate: 4
Staffing hours: 8
Staffing hours: 8
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 3
Date: Sep 29, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #120635 and #120892 to evaluate compliance with federal regulations related to resident care and safety.
Complaint Details
The inspection included complaint investigations #120635 and #120892. The findings substantiated failures in coordinated dialysis care, pressure ulcer prevention, and fall prevention resulting in resident harm.
Findings
The facility failed to have a written agreement with an outside dialysis center for coordinated care of a resident receiving dialysis. It also failed to provide appropriate pressure-relieving devices for a resident at risk for pressure ulcers and lacked a system to monitor wheelchair cushions. Additionally, the facility failed to provide adequate supervision and assistive devices to prevent repeated falls for a resident, resulting in fractures.
Deficiencies (3)
F309: The facility failed to have a written agreement with the outside dialysis center to ensure coordinated care for the resident receiving dialysis services.
F314: The facility failed to provide an appropriate pressure-relieving wheelchair cushion to a resident at risk for pressure ulcers and lacked a policy to assess and monitor such cushions.
F323: The facility failed to provide adequate supervision and assistive devices and failed to perform root cause analysis after a fall, resulting in repeated falls and fractures for a resident.
Report Facts
Resident census: 37
Sample size: 13
Residents receiving dialysis: 1
Falls: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 31, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of 03/01/2016.
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Feb 29, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address multiple deficiencies identified during a prior inspection.
Findings
The facility identified failures in investigating falls, conducting comprehensive assessments, completing care plans, monitoring weights, including Black Box Warnings in care plans, monitoring blood pressure and blood sugar, drug reduction efforts, bowel movement monitoring, RN coverage, dental services, medication availability, infection control, and dietary management. Corrective actions and responsible parties are detailed for each deficiency.
Deficiencies (13)
F225-D The facility failed to thoroughly investigate falls. A nurse's investigation form is now required for all falls and overseen by the Director of Nursing.
F272-E The facility failed to conduct comprehensive assessments. A new MDS coordinator and consulting firm have been engaged to improve assessment accuracy.
F278-D The facility failed to accurately complete assessments for care plan purposes. A care plan assessment library is being developed and monitored.
F279-D The facility failed to develop comprehensive care plans for dental, constipation, and nutritional needs. Education and new tools are being implemented.
F280-D The facility failed to review and revise care plans to meet individual nutrition needs. Dietary manager and MDS coordinator now coordinate updates.
F309-D The facility failed to monitor daily weights as ordered for edema. A log and double charting system have been implemented.
F329-E The facility failed to include Black Box Warnings in care plans. Pharmacist and nursing staff now ensure warnings are included and monitored.
F354-F The facility failed to ensure an RN was on duty for 8 consecutive hours daily. An additional RN was hired to provide coverage.
F412-D The facility failed to ensure dental services for all residents. Social Service Designee and charge nurses now monitor and arrange dental care.
F425-D The facility failed to ensure availability of medications. Nurses are trained on documentation and pharmacy contact procedures.
F428-E The facility failed to monitor blood pressure, blood sugar, drug reduction, and bowel movements adequately. Policies and monitoring responsibilities were established.
F441-F The facility failed to provide adequate isolation precautions and infection control. Staff received inservice training and infection control nurse monitors supplies and infections.
S600-C The facility failed to retain a full-time certified dietary manager. Staff encouraged to complete dietary courses and registered dietician continues oversight.
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 19, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited with deficiencies at the 'F' severity level, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: May 19, 2016
Provider agreement termination date: Aug 19, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Census: 35
Deficiencies: 1
Date: Feb 1, 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.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to employ a full-time certified dietary manager to oversee the dietary department. The current manager was not certified at the time of inspection but was in training to complete certification by August 2016.
Report Facts
Resident census: 35
Inspection Report
Enforcement
Deficiencies: 0
Date: 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 at the facility to be at 'F' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective May 1, 2016, until substantial compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of Payment Effective Date: May 1, 2016
Termination Recommendation Date: Aug 1, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 19, 2014
Visit Reason
The 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.
Deficiencies (2)
F425-D: The facility failed to provide pharmaceutical services to assure timely medication administration as ordered by the physician. Medication aides must notify the Charge Nurse of any medications not received, who will then contact the pharmacy and physician as needed.
F441-F: The facility failed to maintain an infection control program to continually identify infections and prevent their spread. A new policy requires tracking infections by occurrence, with Charge Nurse and Infection Control Nurse responsibilities defined.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 19, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiencies previously cited under regulations 483.60(a),(b) and 483.65 have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.60(a),(b): Previously cited deficiency corrected as of 11/19/2014.
Regulation 483.65: Previously cited deficiency corrected as of 11/19/2014.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: 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.
Complaint Details
The complaint investigation #78844 substantiated that the facility failed to provide timely medication administration and maintain an effective infection control program.
Findings
The facility failed to provide timely medication administration for one resident, resulting in missed doses of a prescribed diuretic. Additionally, the facility did not maintain an effective infection control program to monitor, track, and prevent infections, including a lack of ongoing monitoring and staff re-education.
Deficiencies (2)
F425 Pharmaceutical services were deficient as the facility failed to administer the ordered medication Bumex timely, resulting in 5 missed doses for resident #19.
F441 The facility failed to maintain an infection control program to timely track and trend infections and to re-educate staff when infection trends were identified.
Report Facts
Resident census: 36
Missed medication doses: 5
Residents with infections: 14
Urinary tract infections: 5
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 20, 2014
Visit Reason
The inspection 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 rated as an 'F' level, 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.
Deficiencies (1)
The facility had a widespread 'F' level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 17, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine 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. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for 'E' level deficiencies indicating a pattern of noncompliance with Life Safety Code requirements. These deficiencies posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Jul 17, 2014
Provider agreement termination date: Oct 17, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Kansas Department for Aging and Disability Services. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 22, 2013
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
The report shows that all previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 4
Date: 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.
Complaint Details
The visit was triggered by complaints and a non-compliance revisit related to housekeeping, 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 residents with falls and weight loss, failed to provide adequate treatment and monitoring for pressure ulcers, and failed to ensure adequate supervision and assistive devices to prevent repeated falls for multiple residents.
Deficiencies (4)
483.15(h)(2) Housekeeping and maintenance services were inadequate, with broken floor tiles, stained carpets, and scuffed walls in resident areas.
483.20(d)(3), 483.10(k)(2) The facility failed to review and revise care plans for 5 of 16 residents, resulting in inconsistent care and failure to prevent repeated falls and weight loss.
483.25(c) The facility failed to ensure timely skin assessments and appropriate treatment for pressure ulcers in 3 residents, including lack of documentation and communication.
483.25(h) The facility failed to provide adequate supervision and assistive devices to prevent repeated falls for 5 residents, including failure to follow planned interventions and inconsistent monitoring.
Report Facts
Resident census: 38
Fall risk score: 13
Fall risk score: 22
Fall risk score: 16
Fall risk score: 4
Pressure ulcer size: 1.5
Pressure ulcer size: 1.4
Pressure ulcer size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff AA | Maintenance staff interviewed about housekeeping issues | |
| Staff CC | Housekeeping staff interviewed about cleaning efforts | |
| Staff BB | Administrative staff | Provided quote for tile replacement |
| Staff M | Direct care staff | Reported changes in resident #10 care plan and failure to use pivot pad |
| Staff O | Direct care staff | Reported resident #10 did not use pivot pad as therapy took it |
| Staff E | Direct care staff | Reported resident #10 fall risk interventions |
| Staff J | Direct care staff | Reported resident #10 fall risk interventions |
| Staff K | Direct care staff | Reported resident #10 fall risk interventions |
| Staff Q | Consulting staff | Reported resident #10 continued need for pivot pad |
| Staff L | Administrative nursing staff | Reported on care plan changes and fall interventions |
| Staff Z | Licensed nursing staff | Wound care nurse reporting on pressure ulcer monitoring |
| Staff G | Licensed nursing staff | Reported on fall training and interventions |
| Staff F | Licensed nursing staff | Reported on fall interventions |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 18, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The facility failed to provide adequate housekeeping and maintenance services, failed to update care plans to reflect resident status changes, failed to ensure proper monitoring and treatment of pressure ulcers, and failed to provide adequate supervision and assistive devices to prevent accidents.
Deficiencies (4)
F253-E The facility failed to provide housekeeping and maintenance services to the dining room and beauty shop, including damaged floor tiles and stained carpeting.
F280-E The facility failed to review and revise care plans to reflect changes in resident status or needs, leading to outdated care plans.
F314-D The facility failed to ensure residents received adequate monitoring and treatment for pressure ulcers, including insufficient skin assessments.
F323-E The facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents, including lack of staff education after falls.
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
Follow-Up
Deficiencies: 0
Date: Sep 18, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 17
Date: 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 in the facility.
Findings
The facility identified failures in incident reporting, housekeeping and maintenance, assessment and care planning accuracy, pressure ulcer prevention, supervision and accident prevention, weight monitoring, medication management, staff scheduling, nutrition, food sanitation, infection control, and quality assurance. Corrective actions and staff responsibilities are detailed for each deficiency.
Deficiencies (17)
F225-D The facility failed to thoroughly investigate and report incidents of alleged neglect for falls and fractures to the State agency. The Director of Nursing will ensure proper investigation and reporting.
F253-E The facility failed to provide adequate housekeeping and maintenance services in multiple common areas. Repairs and cleaning have been completed and supervisors will maintain these areas.
F272-E The facility failed to complete Care Area Assessments (CAAs) with comprehensive assessments. Nursing staff will be retrained and monitored to ensure completion.
F278-D The facility failed to accurately complete assessments for care planning. The MDS coordinator will receive education and oversight to improve accuracy.
F279-D The facility failed to develop comprehensive care plans. The MDS coordinator will continue education and monitoring to ensure care plans fit resident needs.
F280-E The facility failed to review and revise care plans to reflect changes in resident status. Care plans will be updated to remain current and individualized.
F314-G The facility failed to prevent pressure ulcers in residents entering without them. Staff will receive in-service training and perform regular skin assessments.
F323-G The facility failed to provide adequate supervision and assistive devices to prevent accidents. Staff will be trained and monitored to use appropriate equipment.
F325-G The facility failed to maintain residents' weight within acceptable parameters. Staff will weigh residents weekly and report changes for physician follow-up.
F329-D The facility failed to ensure residents remain free of unnecessary medications and follow-up on PRN medication. Staff will be trained on protocols and monitoring.
F356-C The facility failed to ensure daily staff posting included shift schedules. Charge nurses will post schedules and be reminded to maintain postings.
F363-F The facility failed to follow planned menus to maintain nutritional values. Menus will be reinstated and dietary staff will comply with dietitian recommendations.
F371-F The facility failed to store, prepare, and serve food in a sanitary manner. Housekeeping and dietary staff will monitor refrigerators and kitchen equipment regularly.
F428-D The facility pharmacist failed to identify drug irregularities and follow-up on PRN medications. The Director of Nursing will review pharmacist reports and hold staff accountable.
F431-D The facility failed to monitor expired stock medication. Certified medication aides will check stock weekly and remove expired medications.
F441-F The facility failed to establish and maintain an infection control program. The infection control nurse and Director of Nursing will revise policies and oversee infection prevention.
F520-F The facility failed to maintain a quality assurance committee that addresses quality of care and life concerns. Meetings have been restarted and will be held regularly with medical director involvement.
Report Facts
Plan of Correction completion date: Aug 25, 2013
State survey end date: Jul 26, 2013
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 16
Date: Jul 26, 2013
Visit Reason
Complaint investigation and health resurvey related to allegations of neglect and falls with fractures at the facility.
Complaint Details
The complaint investigation revealed multiple falls with fractures and injuries, failure to investigate and report neglect, failure to implement fall prevention interventions, and failure to maintain adequate care plans and assessments.
Findings
The facility failed to thoroughly investigate and report incidents of neglect involving multiple residents with falls and fractures. The facility also failed to provide adequate supervision and assistive devices to prevent accidents, maintain nutritional status for a resident with significant weight loss, follow planned menus and recipes, monitor medication expiration, and maintain an effective infection control program. The quality assurance committee was not maintained effectively.
Deficiencies (16)
F225 - The facility failed to thoroughly investigate and report to the State agency incidents of alleged neglect involving 5 residents with falls and fractures, and failed to implement interventions to prevent further falls.
F253 - The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in multiple areas including hallways, dining room, and resident bathrooms.
F272 - The facility failed to complete comprehensive assessments including care area assessments for 5 residents, resulting in incomplete care planning based on individual needs.
F278 - The facility failed to accurately complete assessments for 3 residents, including failure to identify fractures, pressure ulcers, and decline in activities of daily living.
F279 - The facility failed to develop comprehensive care plans for 3 residents, including lack of care plans for pressure ulcers, weight loss, and discharge planning.
F280 - The facility failed to review and revise care plans for 5 residents to provide adequate supervision and assistive devices to prevent falls and accidents, resulting in multiple falls with injuries.
F314 - The facility failed to ensure a resident admitted without pressure ulcers did not develop avoidable stage II pressure ulcers, and failed to perform routine skin assessments and develop interventions.
F323 - The facility failed to ensure 4 residents received adequate supervision and assistive devices to prevent accidents, resulting in falls with fractures and injuries, and failed to assess causes and develop interventions after falls.
F325 - The facility failed to ensure a resident maintained acceptable nutritional status, evidenced by a 15 pound/10.14% weight loss over 6 months, failed to notify physician or family, and failed to develop interventions.
F329 - The facility failed to ensure 3 residents remained free of unnecessary medications, including failure to follow-up on PRN medications for pain and constipation, and inadequate monitoring of resident behaviors.
F356 - The facility failed to post daily nurse staffing information for 3 days of the survey in a clear, readable format in a prominent place accessible to residents and visitors.
F363 - The facility failed to follow planned menus and recipes to ensure meals served met nutritional needs, including failure to use recipes for pureed diets.
F371 - The facility failed to store and prepare food under sanitary conditions, including unlabeled food in resident refrigerator and unclean kitchen equipment.
F428 - The facility pharmacist failed to identify drug irregularities and lack of follow-up on PRN medications for 4 residents, including failure to ensure appropriate care and avoid unnecessary medications.
F441 - The facility failed to establish and maintain an infection control program to track and trend individual resident infections to prevent development and spread of infection.
F520 - The facility failed to maintain an effective quality assurance committee to develop and implement appropriate plans of action to correct identified quality of care and quality of life concerns for all residents.
Report Facts
Resident census: 40
Weight loss: 15
Fall risk score: 14
Fall risk score: 13
PRN medication administrations: 51
PRN medication administrations: 16
PRN medication administrations: 14
Expired medication: 1
Expired medication: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Verified failure to investigate and report falls, failure to notify family of weight loss, and failure to maintain staffing sheets |
| Staff C | Administrative Nursing Staff | Responsible for care plan updates, reported new to position and unsure how to update care plans |
| Staff I | Licensed Nursing Staff | Reported procedures for fall follow-up, lack of care plan updates, and no documentation of PRN follow-up |
| Staff E | Licensed Staff | Verified resident condition and lack of pressure ulcer on admission, reported lack of infection control tracking |
| Staff F | Dietary Staff | Reported no use of recipes for pureed diets and menus based on resident choice |
| Staff G | Consultant Dietary Staff | Reported facility failed to follow planned menus and recipes |
| Staff V | Direct Care Staff | Reported weekly weights and medication expiration monitoring |
| Staff N | Certified Nursing Staff | Reported PRN medication follow-up procedures |
| Staff W | Certified Nursing Staff | Reported behavior monitoring and PRN follow-up procedures |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Mar 25, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.10(b)(11), 483.13(c)(1)(ii)-(iii), (c)(2)-(4), and 483.25(h) were corrected as of 03/16/2013.
Deficiencies (3)
Regulation 483.10(b)(11): Previously cited deficiency corrected as of 03/16/2013.
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiency corrected as of 03/16/2013.
Regulation 483.25(h): Previously cited deficiency corrected as of 03/16/2013.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Date: Feb 15, 2013
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of neglect and failure to notify the physician timely following resident falls.
Complaint Details
The complaint investigation #62925 focused on allegations that the facility failed to notify the physician timely after resident falls and failed to investigate and report incidents of neglect resulting in fractures.
Findings
The facility failed to notify the physician in a timely manner after two falls resulting in a fractured hip and elbow for one resident. The facility also failed to thoroughly investigate and report these incidents to the state agency as required. Additionally, the facility did not provide adequate supervision or assistive devices to prevent repeated falls for the resident.
Deficiencies (3)
F 157: The facility failed to notify the physician timely following two falls for one resident, resulting in a fractured hip and elbow.
F 225: The facility failed to thoroughly investigate and report two incidents of alleged neglect resulting in fractures to the state agency within required timeframes.
F 323: The facility failed to provide adequate supervision and assistive devices to prevent repeated falls for one resident with a history of falls and fluctuating mental and physical ability.
Report Facts
Resident census: 39
Time delay in physician notification: 12.17
Days delay in state agency reporting: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Administrative Licensed Nurse | Reported failure to notify state agency of resident's hip fracture fall due to being overwhelmed with staff loss |
| Staff H | Licensed Nurse | Worked nights of resident's falls; acknowledged failure to notify physician timely and described resident supervision challenges |
| Staff R | Direct Care Staff | Worked nights of resident's falls; described resident's dementia and challenges with supervision |
| Staff D | Direct Care Staff | Reported resident frequently got up unassisted despite staff checks |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Feb 15, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Winfield Rest Haven.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation at Winfield Rest Haven.
Findings
The facility failed to notify the physician timely after accidents, did not thoroughly investigate and report incidents with injuries, and failed to ensure adequate supervision and assistive devices to prevent repeated accidents.
Deficiencies (3)
F157-D: The facility failed to notify the physician in a timely manner following an accident. Staff will be instructed to follow policies for timely notification and pain management.
F225-D: The facility failed to thoroughly investigate and report incidents with injuries to the state agency. Improved incident tracking and reporting procedures will be implemented.
F323-G: The facility failed to ensure adequate supervision and assistive devices to prevent repeated accidents. Care plans will be updated and staff will be inserviced on safety protocols.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 3, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The facility failed to ensure resident 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 and pressure ulcers, and maintain appropriate laundry water temperatures.
Deficiencies (7)
F159-E: The facility failed to allow residents access to their funds, verify responsible parties received quarterly notices, and maintain Medicaid account balances below $1800.00.
F278-D: The facility failed to complete an accurate comprehensive assessment related to planned discharge by verifying the discharge plan on the MDS.
F279-D: The facility failed to develop a plan of care for residents related to fall prevention, including care planning for fall risk and post-fall interventions.
F280-D: The facility failed to review and revise care plans for falls, pressure ulcers, sleeping accommodations, and bed rail preferences as resident preferences changed.
F314-D: The facility failed to provide interventions to reduce pressure ulcers and to change dressings as ordered to promote healing.
F323-D: The facility failed to develop a plan of care for residents related to fall prevention, including use of the Fall Risk assessment tool and care plan reviews after falls.
F441-F: The facility failed to ensure appropriate water temperatures in the laundry by not consistently checking and recording temperatures each shift.
Inspection Report
Follow-Up
Deficiencies: 7
Date: May 3, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as of the revisit date.
Findings
The report shows that all previously cited deficiencies were corrected by the revisit date of May 3, 2012.
Deficiencies (7)
Regulation 483.10(c)(2)-(5) deficiency was corrected by May 3, 2012.
Regulation 483.20(g)-(j) deficiency was corrected by May 3, 2012.
Regulation 483.20(d), 483.20(k)(1) deficiency was corrected by May 3, 2012.
Regulation 483.20(d)(3), 483.10(k)(2) deficiency was corrected by May 3, 2012.
Regulation 483.25(c) deficiency was corrected by May 3, 2012.
Regulation 483.25(h) deficiency was corrected by May 3, 2012.
Regulation 483.65 deficiency was corrected by May 3, 2012.
Inspection Report
Routine
Census: 39
Deficiencies: 7
Date: Apr 3, 2012
Visit Reason
Routine health resurvey of Winfield Rest Haven II, LLC to assess compliance with health and safety regulations.
Findings
The facility had deficiencies in managing residents' personal funds, completing accurate assessments and care plans, preventing pressure ulcers, ensuring adequate supervision to prevent falls, and maintaining infection control including laundry water temperatures.
Deficiencies (7)
F159: Facility failed to obtain consents for handling funds for 2 residents, provide ongoing access to resident funds, verify quarterly statements were received, and ensure Medicaid resident's account balance remained below $1800.
F278: Facility failed to complete an accurate assessment for resident #26 related to discharge planning after resident's plans changed.
F279: Facility failed to develop care plans for 2 residents related to fall prevention despite multiple falls and high fall risk scores.
F280: Facility failed to review and revise care plans for 3 residents including fall prevention, pressure ulcer care, and sleeping accommodations.
F314: Facility failed to prevent development and promote healing of pressure ulcers for 2 residents by not providing pressure relief devices and failing to change dressings as ordered.
F323: Facility failed to provide adequate supervision and assistive devices to prevent accidents and repeated falls for 3 residents.
F441: Facility failed to ensure appropriate laundry water temperatures were maintained and documented, risking inadequate sanitation during a respiratory infection outbreak.
Report Facts
Resident census: 39
Residents with funds handled: 18
Medicaid residents with funds handled: 12
Resident fund account balance: 2008.6
Resident fund account balance: 2639.45
Deficiency counts: 4
Braden scale score: 13
Water temperature: 168
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N018007 POC 25ML11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.
Findings
The Plan of Correction addresses the administrator's use of the PBJ time reading system to verify on-site hours, ensuring compliance with required on-site presence.
Deficiencies (1)
F-851 PBJ: The administrator has been using the PBJ time reading system to record his on-site hours since January 12, 2020, verifying 40 plus hours each week as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Administrator submitting the Plan of Correction and noted in the PBJ time tracking system. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N018007 POC 2TZY11
Visit Reason
This document is a Plan of Correction submitted by Winfield Rest Haven to address deficiencies identified in a prior inspection.
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 fall and head injury policies with enhanced risk assessment and monitoring procedures.
Deficiencies (3)
F309: The agreement with the outside dialysis center is located in the Survey Readiness Book to ensure coordination of care. The Director of Nursing will oversee this coordination.
F314: New T-Gel wheelchair cushions were ordered to replace current cushions. A policy was implemented to monitor and document cushions weekly for cleaning, comfort, and replacement.
F323: The fall and head injury policy was updated to provide guidance on fall monitoring interventions. Daily risk assessment meetings were implemented and nursing staff assigned to monitor residents 24 hours a day.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Randy Ervin | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018007 POC DVYO11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
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