Inspection Reports for
Winfield Senior Living Community
1320 WHEAT ROAD, WINFIELD, KS, 67156-4704
Back to Facility ProfileDeficiencies (last 15 years)
Deficiencies (over 15 years)
24.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
42% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Renewal
Census: 21
Deficiencies: 1
Date: Feb 3, 2026
Visit Reason
The inspection was a licensure resurvey combined with a complaint investigation (complaint number 2729487) conducted to assess compliance with state regulations.
Complaint Details
The visit included a complaint investigation related to complaint number 2729487.
Findings
The facility failed to comply with tuberculosis (TB) screening guidelines for newly hired employees, specifically for a Certified Nurse Aide and a Certified Medication Aide, due to incomplete or outdated TB skin test documentation.
Deficiencies (1)
Infection Control Policies CFR 26-41-207 (b)(5-6)(c): The facility failed to ensure newly hired CNA and CMA employees had required two-step TB skin tests administered within seven days of employment, with documentation missing or tests older than six months at hire.
Report Facts
Census: 21
Newly hired employees reviewed: 4
Residents reviewed: 3
Focused reviews: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 2, 2026
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey conducted on 2026-02-02, which included an attached complaint number 2729487.
Complaint Details
The plan of correction references complaint number 2729487 associated with the licensure resurvey.
Findings
The plan of correction addresses citations identified during the licensure resurvey and complaint investigation conducted on 2026-02-02.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-02-06.
Findings
All deficiencies have been corrected as of the compliance date of 2025-03-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 16
Date: Mar 15, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection, detailing corrective actions, systematic changes, and monitoring plans.
Findings
The facility implemented multiple corrective actions including updating care plans, educating staff on policies and procedures, conducting audits to ensure compliance, and addressing medication management, resident transfers, and safety concerns. The plan asserts substantial compliance with federal Medicare and Medicaid requirements.
Deficiencies (16)
F623-D: Facility provided written notification of the reason and location for facility-initiated resident transfers at time of transfer.
F657-D: Facility updated resident care plans to reflect current transfer status, fluid restrictions, and dialysis completion days with accurate documentation.
F684-D: Facility completed hot liquid assessments and installed water temperature regulators to prevent burns; care plans updated accordingly.
F688-D: Facility updated care plans with current home exercise programs and educated staff on range of motion plans to prevent contracture worsening.
F689-D: Facility updated fall intervention care plans and educated staff on interventions to reduce risk of preventable falls and injuries.
F692-D: Facility reviewed resident weight and nutritional status, updated care plans, and implemented communication protocols to monitor weight loss.
F698-D: Facility updated dialysis and fluid restriction care plans and educated staff on documentation and physician orders for residents receiving dialysis.
F744-D: Facility initiated activity calendar and charting system for memory care residents and educated staff on dementia policy and person-centered activities.
F755-E: Facility ensured certified medication aides and licensed staff count narcotic boxes during shift changes and educated staff on proper documentation.
F756-D: Facility reviewed medication orders and educated staff on drug regimen review policies and medication parameters set by physicians.
F757-D: Facility reviewed medication and treatment orders for safe administration and educated nursing staff and medication aides on related policies.
F758-D: Facility reviewed psychotropic medication indications and gradual dose reduction rationale, educating staff on related policies.
F761-E: Facility educated charge nurses and nursing staff on security of medication cart policies and proper procedures.
F838-F: Facility updated assessment to reflect resources necessary for competent resident care during operations and emergencies and educated leadership.
F880-F: Facility educated staff on proper storage and disposal of face masks, nasal cannulas, and updated Legionella water management policy.
F883-E: Facility reviewed and documented resident immunizations and educated charge nurses on vaccination and declination documentation policies.
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Inspection Report
Routine
Census: 72
Deficiencies: 15
Date: Feb 6, 2025
Visit Reason
Routine inspection of Winfield Senior Living Community to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide written transfer notifications, incomplete care plan revisions, inadequate monitoring of dialysis and fluid restrictions, unsafe medication management, insufficient dementia care activities, lack of proper infection control practices, incomplete pneumococcal vaccination documentation, and an incomplete facility-wide staffing and resource assessment.
Deficiencies (15)
F 0623: The facility failed to provide written notification of the reason and location for a facility-initiated transfer for Resident 44, risking delayed or uncommunicated care.
F 0657: The facility failed to revise Resident 23's care plan to reflect changes in dialysis days and fluid restriction monitoring, and failed to revise Resident 12's care plan to reflect current transfer requirements, risking impaired care.
F 0684: The facility failed to evaluate Resident 27's risks related to handling hot liquids and did not document follow-up assessments after spills, placing the resident at risk for preventable injuries.
F 0688: The facility failed to provide services and treatment to prevent worsening of contractures and maintain range of motion for Resident 38, risking further decline and discomfort.
F 0689: The facility failed to ensure Resident 16's safety by not following care-planned fall interventions, including ensuring a Dycem mat was in place, placing the resident at risk for falls and injuries.
F 0692: The facility failed to identify and implement nutritional interventions for Resident 26's ongoing weight loss, risking malnourishment-related complications.
F 0698: The facility failed to ensure Resident 23 had a physician order for dialysis including indication and failed to monitor fluid restriction, risking adverse outcomes related to dialysis.
F 0744: The facility failed to provide necessary person-centered activities and supervision for Resident 13 with dementia, risking ineffective treatment and decreased quality of care.
F 0755: The facility failed to ensure controlled substances were properly accounted for and reconciled between shifts, risking medication misappropriation or diversion.
F 0756: The facility failed to ensure the consultant pharmacist identified and made recommendations regarding Resident 12's Midodrine medication, risking unnecessary medication and side effects.
F 0757: The facility failed to ensure safe medication administration for Resident 12's Midodrine medication, including holding medication for high blood pressure, risking unnecessary medication and side effects.
F 0761: The facility failed to ensure safe medication storage of one medication cart which was found unlocked, risking diversion and ineffective medication regimen.
F 0838: The facility failed to conduct a thorough facility-wide assessment to determine resources necessary for competent resident care during day-to-day operations and emergencies, affecting all residents.
F 0880: The facility failed to ensure used face masks and oxygen cannulas were stored or disposed of in a sanitary manner and lacked a Legionella disease program, risking infectious disease transmission.
F 0883: The facility failed to offer or obtain informed declinations or physician-documented contraindications for Pneumococcal Conjugate Vaccine (PCV20) for several residents, increasing risk for pneumonia complications.
Report Facts
Resident census: 72
Resident census: 47
Weight loss: 26.4
Medication doses: 13
Medication doses: 6
Medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding facility policies, care plans, and deficiencies |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding care plans, medication administration, and monitoring |
| Certified Nurse Aide M | Certified Nurse Aide | Provided observations and statements related to resident care and medication |
| Certified Medication Aide R | Certified Medication Aide | Provided statements about staffing and resident activities |
| Administrative Nurse E | Administrative Nurse / Infection Preventionist | Provided statements regarding infection control and immunization tracking |
| Licensed Nurse I | Licensed Nurse | Provided statements about medication cart security |
| Activity Z | Activity Director | Provided statements about activity programming on memory unit |
Inspection Report
Routine
Census: 72
Deficiencies: 16
Date: Feb 6, 2025
Visit Reason
Routine health resurvey and inspection of Winfield Senior Living Community to assess compliance with regulatory requirements including care plans, medication management, infection control, and resident safety.
Findings
The facility had multiple deficiencies including failure to provide written transfer notices, revise care plans to reflect current resident needs, evaluate risks related to hot liquids, ensure fall prevention interventions, identify and intervene on weight loss, monitor dialysis orders and fluid restrictions, provide person-centered dementia care activities, ensure accurate controlled substance reconciliation, safe medication administration, proper medication storage, conduct a thorough facility-wide assessment, maintain infection control practices, and offer pneumococcal immunizations.
Deficiencies (16)
F 623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notification of the reason and location for a facility-initiated transfer for Resident 44, risking delayed or uncommunicated care.
F 657 Care Plan Timing and Revision: The facility failed to revise Resident 12's care plan to reflect current transfer requirements and Resident 23's hospice care interventions, risking impaired care.
F 684 Quality of Care: The facility failed to evaluate Resident 27's risks and abilities related to handling hot liquids, placing the resident at risk for preventable accidents and injuries.
F 688 Increase/Prevent Decrease in ROM/Mobility: The facility failed to provide services to prevent worsening contractures in Resident 38's left hand, risking discomfort and decreased range of motion.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure Resident 16's safety related to following care-planned fall interventions, including use of a Dycem mat, placing the resident at risk for falls and injuries.
F 692 Nutrition/Hydration Status Maintenance: The facility failed to identify and implement nutritional interventions for Resident 26's ongoing weight loss, risking malnourishment-related complications.
F 698 Dialysis: The facility failed to ensure Resident 23 had a physician order for dialysis including indication and failed to monitor fluid restriction, risking adverse outcomes related to dialysis.
F 744 Treatment/Service for Dementia: The facility failed to provide necessary person-centered activities and interventions for Resident 13's dementia, including close supervision to prevent wandering and falls, risking ineffective treatment and decreased quality of care.
F 755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to ensure controlled substances were accurately accounted for and reconciled between shifts, risking medication misappropriation and diversion.
F 756 Drug Regimen Review, Report Irregular, Act On: The facility failed to ensure the consultant pharmacist identified and made recommendations related to Resident 12's Midodrine medication, risking unnecessary medications and side effects.
F 757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to ensure safe administration of Resident 12's Midodrine medication, risking unnecessary medications and side effects.
F 758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure appropriate indication or physician rationale for Resident 26's antipsychotic medication and failed to document rationale for continued use of as-needed psychotropic medications for Resident 1, risking unnecessary medications and adverse effects.
F 761 Label/Store Drugs and Biologicals: The facility failed to ensure safe medication storage of one medication cart left unlocked, risking diversion and ineffective medication regimen.
F 838 Facility Assessment: The facility failed to conduct a thorough facility-wide assessment to determine resources necessary for competent resident care during day-to-day operations and emergencies, affecting all residents.
F 880 Infection Prevention & Control: The facility failed to ensure used face masks and oxygen cannulas were stored or disposed of in a sanitary manner and failed to implement a Legionella disease program, risking infectious disease transmission.
F 883 Influenza and Pneumococcal Immunizations: The facility failed to offer or obtain informed declinations or physician-documented contraindications for Pneumococcal Conjugate Vaccine (PCV20) for multiple residents, increasing risk for pneumococcal disease complications.
Report Facts
Resident census: 72
Weight loss: 26.4
Medication administration blood pressure: 177
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-01-07.
Findings
All deficiencies have been corrected as of the compliance date of 2025-01-08, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The document is a plan of correction submitted in response to findings from the licensure resurvey conducted on January 7, 2025.
Findings
The plan of correction addresses citations identified during the licensure resurvey of the facility on January 7, 2025.
Inspection Report
Renewal
Census: 17
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The inspection was a licensure resurvey conducted to assess compliance with regulatory requirements for the facility.
Findings
The facility failed to perform a required functional capacity screening for Resident 3 at least once every 365 days as mandated by state regulations.
Deficiencies (1)
K.A.R. 26-41-201 (c) (1) The facility did not ensure a functional capacity screening was performed for Resident 3 within the past 365 days.
Report Facts
Census: 17
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-08-26.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2024-09-17. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 17, 2024
Visit Reason
This document is a Plan of Correction submitted by Winfield Senior Living community to address deficiencies cited in a prior inspection.
Findings
The facility plans to ensure timely activation and revision of care plans and to provide Activities of Daily Living (ADL) care according to policies and orders. Staff education and frequent audits are part of the corrective actions.
Deficiencies (2)
F657-D Care Plan Timing and Revision: The facility will ensure that all care plans are activated and revisions are made timely. Staff will be educated on reporting resident changes to update care plans.
F676-D Activities Daily Living (ADLs) Mntn Abilities: The facility will provide ADL care for all residents according to written policies and orders. Staff are educated to report refusals immediately to the charge nurse.
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Date: Aug 26, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with care plan development and provision of necessary bathing services for residents.
Findings
The facility failed to revise Resident 1's care plan to include interventions related to personal hygiene and failed to provide necessary bathing services to maintain good grooming and personal hygiene. Staff did not notify the resident's family member when the resident refused bathing as required.
Deficiencies (2)
F 0657: The facility failed to revise Resident 1's care plan to reflect interventions related to personal hygiene, including notification of family when the resident refused bathing.
F 0676: The facility failed to ensure staff provided Resident 1 with necessary bathing services to maintain good grooming and personal hygiene, and failed to notify family when the resident refused bathing.
Report Facts
Resident census: 40
Days without bath: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Interviewed regarding bathing services and documentation |
| LN C | Licensed Nurse | Interviewed regarding bathing schedule and family notification |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding family notification protocol |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Aug 26, 2024
Visit Reason
A complaint survey was conducted regarding allegations in KS00189594 which revealed noncompliance related to care plan timing and revision and activities of daily living.
Complaint Details
The complaint investigation revealed substantiated allegations related to failure to revise care plans and provide adequate bathing services, including failure to notify family members when the resident refused bathing.
Findings
The facility failed to revise Resident 1's care plan to reflect interventions related to personal hygiene and failed to provide necessary bathing services to maintain good grooming and personal hygiene. Staff did not notify the resident's family member when the resident refused bathing as required by facility policy.
Deficiencies (2)
F 657 Care Plan Timing and Revision: The facility failed to revise Resident 1's care plan to include notification of the resident's family member when the resident refused bathing.
F 676 Activities Daily Living (ADLs)/Mntn Abilities: The facility failed to provide Resident 1 with necessary bathing services to maintain good grooming and personal hygiene and did not notify the family when the resident refused bathing.
Report Facts
Census: 40
Days without bath: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide D | Certified Nurse Aide | Interviewed regarding bathing refusals and documentation |
| Licensed Nurse C | Licensed Nurse | Interviewed regarding bathing schedule and family notification |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding family notification protocol |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-01-11.
Findings
All deficiencies have been corrected as of the compliance date of 2024-01-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 10, 2024
Visit Reason
This document is a plan of correction submitted in response to findings from the licensure resurvey conducted on January 10 and 11, 2024.
Findings
The plan of correction addresses citations identified during the licensure resurvey of the facility on the specified dates.
Inspection Report
Renewal
Census: 19
Deficiencies: 3
Date: Jan 10, 2024
Visit Reason
The inspection was a licensure resurvey conducted on 01/10/24 and 01/11/24 to assess compliance with regulatory requirements for the facility's continued licensure.
Findings
The facility was found deficient in conducting annual functional capacity screenings and negotiated service agreement reviews for a resident. Additionally, the facility failed to comply with tuberculosis screening guidelines for newly admitted residents and newly hired staff.
Deficiencies (3)
K.A.R. 26-41-201 (c)(1) The facility failed to ensure designated staff conducted a functional capacity screening for resident R2 at least once every 365 days.
K.A.R. 26-41-202 (d)(1) The facility failed to ensure designated staff reviewed and revised the negotiated service agreement for resident R2 at least once every 365 days.
K.A.R. 26-41-207 (c) The facility failed to comply with tuberculosis screening guidelines by not completing required TB tests within seven days of admission for resident R1 and newly hired Certified Medication Aide C.
Report Facts
Census: 19
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Named in tuberculosis screening deficiency |
| LN A | Licensed Nurse | Interviewed regarding deficiencies and confirmed missing documentation |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
A revisit survey was conducted on 06/06/23-06/07/23 to verify correction of all previous deficiencies cited on 04/19/23.
Findings
All deficiencies have been corrected as of the compliance date of 05/06/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-04-19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2023-05-06, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-04-19.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2023-05-06, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 5
Date: Apr 19, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home to assess compliance with health and safety regulations.
Findings
The facility was found deficient in multiple areas including failure to prevent resident falls, inadequate hydration, improper pain management, unsanitary food storage and preparation, and lack of documentation for resident vaccinations.
Deficiencies (5)
F 0689: The facility failed to provide safe ambulation with planned interventions for Resident R34, resulting in a fall and a bruise to the back due to staff not using a gait belt or walker as required.
F 0692: The facility failed to provide adequate hydration for dependent Resident R99, who was observed with dry lips, deep tongue grooves, an empty water cup out of reach, and received only two to four cups of water daily from 04/12/23 to 04/18/23.
F 0697: The facility failed to ensure appropriate pain control for Resident R99 by not ensuring the resident swallowed prescribed pain medication, resulting in untreated pain.
F 0812: The facility failed to store and prepare food under sanitary conditions, including expired or improperly labeled food items, creating potential for food borne illness.
F 0883: The facility failed to provide proof of vaccination or declination for the 2022-2023 influenza or pneumococcal vaccines for three of five residents reviewed.
Report Facts
Residents sampled: 14
Residents affected: 43
Fluid intake: 500
Fluid intake: 960
Medication dosage: 325
Medication dosage: 650
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide J | Certified Nurse Aide | Mentioned in relation to fall incident and hydration care |
| Licensed Nurse G | Licensed Nurse | Mentioned regarding gait belt use during ambulation |
| Licensed Nurse H | Licensed Nurse | Mentioned regarding gait belt use, hydration, and pain medication administration |
| Certified Medication Aide R | Certified Medication Aide | Administered crushed pain medication to Resident R99 |
| Administrative Nurse D | Administrative Nurse | Provided statements on gait belt use, hydration, pain management, and vaccination documentation |
| Dietary Staff CC | Dietary Staff | Provided information on food storage and preparation deficiencies |
| Dietary Staff BB | Dietary Staff | Provided information on food storage and preparation deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Apr 19, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the Annual Survey conducted on April 19, 2023.
Findings
The Plan of Correction addresses multiple deficiencies including fall prevention, nutrition and hydration, pain management, food procurement and storage, immunizations, and sanitation of the soiled work room. The facility outlines corrective actions, education, and monitoring plans for each deficiency.
Deficiencies (6)
F-689-D Free of accidents hazards/supervision/devices: The facility will use planned interventions to prevent falls while ambulating residents.
F692-G Nutrition/Hydration Status Maintenance: Resident needs were met at the time of observation with education on hydration and nutrition provided to staff.
F697-D Pain Management: The facility will provide adequate pain management for all residents with staff education on medication consumption.
F812-F Food Procurement, store/prepare/serve sanitary: Food will be stored and prepared under sanitary conditions with staff education on proper storage and expiration dates.
F883-D Influenza and Pneumococcal Immunizations: The facility will ensure each resident has proof of vaccination or declination for 2022-2023.
S894-C Soiled Work Room: The facility will ensure all trash cans and linens are covered at all times with staff education on lids for soiled linen and trash bins.
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 5
Date: Apr 19, 2023
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements following previous deficiencies.
Findings
The facility failed to provide adequate fall prevention interventions, hydration, pain management, sanitary food storage and preparation, and documentation of influenza and pneumococcal immunizations for residents.
Deficiencies (5)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide safe ambulation with planned interventions for Resident 34, resulting in a fall and injury.
F 692 Nutrition/Hydration Status Maintenance: The facility failed to provide adequate hydration for dependent Resident 99, who was observed with dry lips, deep tongue grooves, and insufficient fluid intake.
F 697 Pain Management: The facility failed to ensure Resident 99 swallowed pain medication, resulting in inadequate pain control.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to store and prepare food under sanitary conditions, including expired or unlabeled food items, risking foodborne illness.
F 883 Influenza and Pneumococcal Immunizations: The facility failed to provide proof of vaccination or declination for influenza and pneumococcal vaccines for three of five residents reviewed.
Report Facts
Resident census: 43
Residents sampled: 14
Residents reviewed for immunizations: 5
Fluid intake: 2
Fluid intake: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide J | Certified Nurse Aide | Assisted Resident 34 and Resident 99; stated gait belt use and hydration expectations |
| Licensed Nurse G | Licensed Nurse | Stated gait belts should be used when ambulating Resident 34 |
| Licensed Nurse H | Licensed Nurse | Observed Resident 99 with pain and un-swallowed medication; stated gait belt use and hydration expectations |
| Certified Medication Aide R | Certified Medication Aide | Administered crushed Tylenol to Resident 99 after initial dose was pocketed |
| Administrative Nurse D | Administrative Nurse | Stated expectations for gait belt use, hydration, medication administration, and immunization documentation |
| Dietary Staff CC | Dietary Staff | Reported food storage and labeling concerns in kitchen |
| Dietary Staff BB | Dietary Staff | Provided food storage guidelines and labeling policy information |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-12-20.
Findings
All deficiencies have been corrected as of the compliance date of 2023-01-09, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 17
Deficiencies: 5
Date: Dec 20, 2022
Visit Reason
The inspection was a licensure resurvey with an attached complaint investigation number 171380 conducted on 12/19/2022 and 12/20/2022 at Winfield Senior Living Community.
Complaint Details
The inspection included complaint number 171380.
Findings
The facility was found deficient in multiple areas including failure to revise negotiated service agreements based on residents' functional capacity changes, lack of documentation of the licensed nurse responsible for health care service plans, incomplete resident incident documentation, failure to conduct quarterly emergency preparedness plan reviews, and noncompliance with tuberculosis screening requirements.
Deficiencies (5)
K.A.R. 26-41-202 (d) (2) The Administrator failed to revise the resident's Negotiated Service Agreement based on changes in the Functional Capacity Screen and did not include descriptions of services or payor sources for outside services for resident R1.
K.A.R. 26-41-204 (d) The Administrator failed to ensure the Negotiated Service Agreement contained the name of the licensed nurse responsible for implementation and supervision of the Health Care Service Plan for residents R1, R2, and R3.
K.A.R. 26-41-105 (f) (11) The Administrator failed to ensure resident records included documentation of all incidents, symptoms, actions taken, and results for residents R1, R2, and R3.
K.A.R. 26-41-104 (d) (3) The Administrator failed to review the facility's emergency management plan quarterly with staff and residents as required.
K.A.R. 26-41-207 (c) The Administrator failed to ensure compliance with tuberculosis screening guidelines for resident R2, lacking documentation of the required two-step TB test within seven days of residency.
Report Facts
Resident census: 17
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 19, 2022
Visit Reason
This document is a plan of correction submitted in response to findings from a licensure resurvey with an attached complaint investigation conducted on 12/19/2022 and 12/20/2022.
Complaint Details
The inspection was conducted with an attached complaint number 171380.
Findings
The plan of correction addresses citations identified during the licensure resurvey and complaint investigation for the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-10-03.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-10-03. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-10-03.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-10-03. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Census: 43
Deficiencies: 3
Date: Sep 27, 2022
Visit Reason
The plan of correction addresses deficiencies identified during a Targeted Infection Control Survey/COVID-19 Focused Survey conducted on 09/27/22 and related investigations of abuse, neglect, accident hazards, and failure to report incidents.
Findings
The facility was found in compliance with COVID-19 infection control practices but failed to ensure resident safety and supervision, resulting in immediate jeopardy to a cognitively impaired resident. The facility also failed to report an injury accident to the state agency within the required timeframe and did not maintain a safe environment free of accident hazards on the memory care unit.
Deficiencies (3)
F600-J: The facility neglected to ensure cognitively impaired Resident 1's safety while she remained outside unsupervised for 1 hour and 50 minutes in high temperatures, resulting in altered mental status and hospitalization.
F609-D: The facility failed to report an injury accident involving Resident 1 to the state agency within five days as required.
F689-J: The facility failed to provide an environment free of accident hazards when a bathroom door was removed and left unsecured, resulting in Resident 1 sustaining a head injury and placing other memory care residents at risk.
Report Facts
Resident census: 43
Residents in memory care unit: 10
Residents in sample reviewed for accidents: 3
Residents in sample reviewed for lack of supervision: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Observed Resident 1 injured and notified Licensed Nurse G |
| Licensed Nurse G | Licensed Nurse | Called 911 for emergency medical services for Resident 1 |
| Tomisha Jordan | Executive Director | Submitted the plan of correction |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Sep 27, 2022
Visit Reason
The inspection was conducted as a partial extended survey with complaint investigations #174911 and #175055, focusing on infection control and allegations of neglect and failure to report incidents.
Complaint Details
The visit was complaint-related, investigating allegations of neglect and failure to report incidents. The complaint investigations #174911 and #175055 were part of the survey.
Findings
The facility failed to ensure the safety of a cognitively impaired resident left unsupervised outside in extreme heat, resulting in emergency hospitalization. Additionally, the facility failed to report a resident's injury fall to the state agency within required timeframes and did not maintain a safe environment free of accident hazards, leading to a resident's fall and serious injury.
Deficiencies (3)
F600: The facility neglected to ensure cognitively impaired Resident 1's safety by leaving her unsupervised outside for nearly two hours in 97°F heat, resulting in altered mental status and hospitalization.
F609: The facility failed to report Resident 1's injury fall to the state agency within five days as required.
F689: The facility failed to provide an environment free of accident hazards by leaving a bathroom door removed and unsecured in a memory care unit, resulting in Resident 1 falling and sustaining a subdural hematoma and skull fracture.
Report Facts
Resident census: 43
Resident census in sample: 3
Duration resident left unsupervised outside: 110
Resident body temperature: 102.5
Resident BIMS score: 3
Resident BIMS score: 4
Date bathroom door removed: Aug 12, 2022
Date of resident fall: Sep 22, 2022
Date of nurse observation of fall injury: Sep 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Noted resident outside in heat with altered mental status and called physician for emergency room transfer. |
| Certified Nurse Aide F | Certified Nurse Aide | Let resident outside and later assisted resident outside again, unaware if fluids were provided. |
| Licensed Nurse G | Licensed Nurse | Observed resident after fall with head injury, called physician and EMS, and received hospital CT scan results. |
| Certified Nurse Aide M | Certified Nurse Aide | Discovered resident lying on floor after fall in unsecured room and notified nurse. |
| Maintenance Staff U | Maintenance Staff | Removed bathroom door and placed it in unsecured room, failed to secure it. |
| Administrative Staff A | Administrative Staff | Acknowledged failure to report resident fall to state agency and improper door placement. |
| Administrative Nurse D | Administrative Nurse | Reported maintenance staff should not have left door unsecured. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Nov 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation (#167362) by the Kansas Department for Aging and Disability Services on behalf of CMS due to concerns about the facility's compliance with 42 CFR 483 subpart B.
Complaint Details
The complaint investigation #167362 found the facility not in substantial compliance due to failure to initiate CPR on a resident with a 'Full Code' status. The immediate jeopardy was identified and removed after corrective actions were implemented.
Findings
The facility failed to initiate cardiopulmonary resuscitation (CPR) on a resident with a 'Full Code' status who was found unresponsive and without a pulse. This failure placed the resident and 13 other residents with 'Full Code' status in immediate jeopardy. The immediate jeopardy was removed after the facility implemented a corrective plan including staff training and audits.
Deficiencies (1)
F 678 CFR 483.24(a)(3) Personnel failed to initiate CPR on a resident with a 'Full Code' status found unresponsive and pulseless. This failure placed the resident and 13 other residents desiring resuscitation in immediate jeopardy.
Report Facts
Resident census: 40
Sample size: 13
Date of survey: Nov 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in failure to initiate CPR on resident |
| CNA M | Certified Nurse Aide | Not CPR certified, found resident unresponsive and alerted CMA |
| CMA R | Certified Medication Aide | CPR certified, assessed resident but did not initiate CPR |
| Administrative Nurse D | Administrative Nurse | Expected CPR initiation when resident found unresponsive |
| Administrative Staff A | Administrative Staff | Informed of Immediate Jeopardy and notified action needed |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 29, 2021
Visit Reason
This document is a Plan of Correction submitted by Winfield Senior Living in response to deficiencies related to cardiopulmonary resuscitation (CPR) policy and training.
Findings
The facility identified issues with staff knowledge and training on CPR procedures. The plan outlines corrective actions including staff training, audits, and ongoing monitoring to ensure compliance with CPR policy.
Deficiencies (2)
F0000: The facility failed to ensure all staff were trained and knowledgeable about the CPR policy and procedures. A full house audit and staff training plan were implemented to address this.
F678-K: The facility did not fully comply with education requirements for CPR. A detailed education and monitoring plan was established to ensure staff competency and policy adherence.
Report Facts
Training completion date: Nov 30, 2021
Audit start date: Nov 23, 2021
Inspection Report
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
This document is a Plan of Correction submitted in response to a deficiency-free survey conducted on November 18, 2021.
Findings
The survey found no deficiencies at the facility, indicating compliance with all regulatory requirements at the time of inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The inspection was conducted as a health survey to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the regulatory requirements for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 29, 2021
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 29, 2021
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report documents completion of corrective actions for multiple regulatory items.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 8, 2021
Visit Reason
This document is a plan of correction related to deficiencies found during an inspection of Winfield Senior Living Community on March 8, 2021.
Findings
No specific deficiencies or findings are detailed in this plan of correction document.
Inspection Report
Renewal
Census: 15
Deficiencies: 7
Date: Mar 8, 2021
Visit Reason
The inspection was a licensure resurvey conducted on 03/03/2021, 03/04/2021, and 03/08/2021 to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in multiple areas including failure to conduct required functional capacity screenings annually, incomplete negotiated service agreements lacking licensed nurse identification, failure to perform annual medication self-administration assessments, improper documentation of medication administration responsibilities, medication storage issues including lack of expiration dating on insulin pens, lack of quarterly emergency preparedness training for staff and residents, and failure to comply with tuberculosis screening requirements for new employees.
Deficiencies (7)
KAR 26-41-201 (c) (1) The administrator failed to ensure the functional capacity screening for resident #121 was conducted at least once every 365 days.
KAR 26-41-204 (d) The administrator failed to ensure each resident's negotiated service agreement included the name of the licensed nurse responsible for implementation and supervision of the health care service plan for 3 residents.
KAR 26-41-205 (a) (1) The administrator failed to ensure the licensed nurse performed an annual assessment for self-administration of medications for resident #121.
KAR 26-41-205 (b) The administrator failed to ensure the negotiated service agreement identified who was responsible for administration and management of selected medications for resident #121.
KAR 26-41-205 (h) (4) The administrator failed to ensure licensed nurses did not administer medication beyond the manufacturer's recommended expiration date for insulin pens for 5 residents.
KAR 26-41-104 (d) (3) The administrator failed to provide quarterly emergency and disaster preparedness training to staff and residents.
KAR 26-41-207 (c) The administrator failed to ensure compliance with tuberculosis screening guidelines for a newly hired employee lacking evidence of a 2-step TB test within 7 days of hire.
Report Facts
Census: 15
Residents with insulin pen expiration issues: 5
Residents reviewed for negotiated service agreement: 3
Residents sampled for medication self-administration assessment: 3
Newly hired employees reviewed for TB screening: 1
Inspection Report
Routine
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
The inspection was a special infection control survey for COVID-19 conducted at the facility.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 17, 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 CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a COVID-19 survey conducted on June 16, 2020.
Findings
The facility was found to be deficiency free during the COVID-19 survey conducted on June 16, 2020.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 13, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2020-02-04.
Findings
All deficiencies have been corrected as of the compliance date of 2020-03-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 13, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2020-02-04.
Findings
All deficiencies have been corrected as of the compliance date of 2020-03-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Feb 20, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies related to fall interventions, nebulizer kit disinfection and storage, insulin administration, blood sugar and blood pressure monitoring, and notification of physicians when parameters are out of range.
Deficiencies (5)
F657-D, F689-D: Care plans R42, R41, and R17 will be revised to reflect current fall interventions. Nursing staff will be re-educated on fall policy and incident reporting to ensure timely intervention and root cause analysis.
F695-D: Resident R32’s nebulizer kit will be replaced, disinfected, and stored appropriately. Licensed nurses will be re-educated on proper nebulizer kit disinfection and storage procedures.
F755-D: Resident R41 will receive insulin per order and notify physician if blood sugars are outside parameters. Licensed nurses will be re-educated on notification and holding insulin orders.
F756-D: Resident R13 will notify physician of blood pressure readings out of parameters and have adequate monitoring. Pharmacist and nurses will be educated and audits conducted on blood pressure and blood sugar parameters.
F757-D: Residents R13 and R19’s blood pressures and R19’s blood sugars out of parameters will be notified to physicians. Licensed nurses will be re-educated on parameters and notification requirements.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 7
Date: Feb 4, 2020
Visit Reason
Health Resurvey and Complaint Investigation for multiple residents regarding care plan revisions, fall prevention, medication administration, and respiratory care.
Complaint Details
Complaint investigation revealed failures in care plan revisions, fall prevention interventions, medication administration, and respiratory equipment cleaning.
Findings
The facility failed to timely review and revise care plans following resident falls, implement immediate fall prevention interventions, properly clean and store nebulizer equipment, and follow physician orders for insulin administration and blood pressure monitoring. Medication irregularities and lack of physician notification were also noted.
Deficiencies (7)
Care plan revisions were not timely following falls for Residents 42, 41, and 17, with inadequate immediate interventions to prevent further falls.
Resident 42's care plan lacked communication of interventions such as storing briefs in dresser and keeping bathroom door unlocked until two days after fall.
Resident 17 had multiple falls with delayed or absent care plan interventions and inadequate fall investigations lacking root cause analysis.
Resident 41's insulin was held 12 times without physician notification or orders, including failure to notify physician of blood sugar above 350.
Nebulizer equipment for Resident 32 was not properly cleaned or stored, increasing risk of respiratory infection.
Resident 13 received antihypertensive medications during episodes of hypotension without physician notification or follow-up.
Resident 19 received antihypertensive medications despite blood pressure readings outside ordered parameters without medication hold or physician notification.
Report Facts
Resident census: 47
Insulin doses not administered: 12
Blood sugar reading: 385
Blood pressure readings below parameter: 6
Resident falls: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Reported fall protocol and resident redirection for Resident 42 |
| CNA N | Certified Nursing Assistant | Reported resident fall risk and interventions for Resident 42 |
| LN K | Licensed Nurse | Reported care plan revision responsibilities and fall risk for Resident 42 |
| Administrative Nurse D | Administrative Nurse | Confirmed fall investigation deficiencies and medication administration issues |
| CMA R | Certified Medication Aide | Reported medication administration and supplement intake for Resident 41 |
| LN I | Licensed Nurse | Described nebulizer cleaning procedure for Resident 32 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 28, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-08-28.
Findings
All deficiencies have been corrected as of the compliance date of 2019-09-27, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Aug 28, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#143528) regarding the facility's failure to provide adequate supervision and assistive devices to prevent a resident fall.
Complaint Details
The complaint investigation #143528 found the facility failed to provide adequate supervision and assistive devices to prevent a fall for Resident 1. The fall resulted in injuries including a nasal bone fracture and facial hematoma. The facility policy required gait belt use, but staff did not follow it.
Findings
The facility failed to ensure adequate supervision and gait belt use for Resident 1, who fell while toileting, resulting in injuries including a nasal bone fracture and facial hematoma. The facility policy requires gait belt use during transfers, but staff did not comply.
Deficiencies (1)
CFR 483.25(d) Accidents. The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or assistive devices to prevent a fall for Resident 1. Staff removed the gait belt and unlocked wheelchair brakes, leading to the resident falling and sustaining injuries.
Report Facts
Resident census: 38
Fall Risk Tool score: 15
Complaint investigation number: 143528
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in the finding for failing to provide adequate supervision and gait belt use leading to resident fall |
| LN C | Licensed Nurse | Assessed resident after fall and called EMS |
| Administrative Nurse B | Administrative Nurse | Verified facility staff were to use gait belts with transfers |
| CNA F | Certified Nurse Aide | Observed assisting resident with gait belt during transfer |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 17, 2019
Visit Reason
This document is a Plan of Correction submitted by Winfield Senior Living in response to deficiencies identified during a prior inspection.
Findings
The Plan of Correction addresses issues related to improper gait-belt usage during resident transfers and toileting, with corrective actions including staff re-education, audits, and ongoing monitoring.
Deficiencies (1)
F689-D: RN Nurse re-educated CNA on proper gait-belt usage while transferring and toileting resident R1. Nursing administration will conduct audits and provide continued education to ensure safety with transfers.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-01-28.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2019-02-27, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-01-28.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2019-02-27, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Feb 27, 2019
Visit Reason
This document is a Plan of Correction submitted by Winfield Senior Living Community in response to deficiencies cited during a prior inspection, addressing allegations of exploitation/misappropriation of money, catheter care, and kitchen maintenance issues.
Findings
The facility was cited for issues including exploitation/misappropriation of resident funds, improper catheter care, and unsanitary conditions in the kitchen and maintenance areas. Corrective actions include staff education, audits, cleaning, repairs, and ongoing monitoring reported to the QAPI Committee.
Deficiencies (5)
F609-D: For Resident #10, an allegation of exploitation/misappropriation of money was reported to the State Agency. Staff were re-educated on timely reporting of lost or misappropriated funds.
F610-D: For Resident #10, a completed investigation was submitted to KDADS. Staff were educated on timely investigations of missing resident funds.
F690-D: For Resident #33, catheter drainage bag was properly placed and education was provided to resident and staff on catheter care. Monitoring and audits were planned to ensure compliance.
F812-F: No specific resident affected. Multiple cleaning and repair actions were completed in the dry storage room and kitchen equipment to ensure sanitary conditions.
F921-F: No specific resident affected. Ceiling vents, walls, floors, and kitchen areas were cleaned and repaired. Maintenance and dietary staff were educated on maintaining a safe and sanitary environment.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 28, 2019
Visit Reason
A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2019-02-27.
Deficiencies (1)
The facility had a level "F" deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 5
Date: Jan 28, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #136558 and #137507.
Complaint Details
The complaint investigation involved allegations of exploitation/misappropriation of money for resident #10, which was not reported timely to the state agency and was not thoroughly investigated in a timely manner.
Findings
The facility failed to report and thoroughly investigate an allegation of exploitation/misappropriation of money for one resident. Additionally, the facility failed to provide proper catheter care to prevent urinary tract infections and maintain a clean and sanitary dietary department and kitchen environment.
Deficiencies (5)
F 609: The facility failed to report an allegation of exploitation/misappropriation of money for resident #10 to the state agency as required.
F 610: The facility failed to thoroughly investigate timely the missing money allegation for resident #10.
F 690: The facility failed to ensure proper handling of the catheter drainage bag for resident #33 to prevent urinary tract infections.
F 812: The facility failed to maintain a clean and sanitary dietary department, with multiple areas of grime, debris, and grease buildup in the kitchen.
F 921: The facility failed to provide maintenance services for the kitchen to ensure a safe and sanitary environment, including buildup of dust, grime, rust, broken flooring, and sagging ceiling areas.
Report Facts
Resident census: 38
Missing money amount: 40
Number of residents reviewed: 13
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jul 3, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed with regulation numbers 26-41-204(e), 26-41-205(d)(4), 26-41-104(d), and 26-41-207(b)(5-6)(c) were corrected as of the revisit date.
Deficiencies (4)
Regulation 26-41-204(e) deficiency was corrected as of 07/03/2018.
Regulation 26-41-205(d)(4) deficiency was corrected as of 07/03/2018.
Regulation 26-41-104(d) deficiency was corrected as of 07/03/2018.
Regulation 26-41-207(b)(5-6)(c) deficiency was corrected as of 07/03/2018.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jul 3, 2018
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (4)
Regulation 26-41-204 (e): Previously cited deficiency corrected as of 07/03/2018.
Regulation 26-41-205 (d) (4): Previously cited deficiency corrected as of 07/03/2018.
Regulation 26-41-104 (d): Previously cited deficiency corrected as of 07/03/2018.
Regulation 26-41-207 (b) (5-6) (c): Previously cited deficiency corrected as of 07/03/2018.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 15, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for Winfield Senior Living.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan linked to a previous deficiency report.
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 4
Date: Jun 6, 2018
Visit Reason
The visit was a resurvey conducted on 6/4, 6/5, and 6/6/2018 to assess compliance with previously identified deficiencies at the assisted living facility.
Findings
The facility failed to ensure licensed nurse delegation for nursing procedures such as blood glucose monitoring, checking for bruit, and dialing insulin dosage on insulin pens to certified medication aides. The facility also failed to conduct quarterly reviews of the emergency management plan with staff and residents and did not comply with tuberculosis testing guidelines for residents and new employees.
Deficiencies (4)
26-41-204 (e) Delegation of Duties: The administrator failed to ensure licensed nurse delegation for blood glucose testing and checking for bruit to certified medication aides, which is not part of their curriculum.
26-41-205 (d)(4) Delegation of Medication Administration: The administrator failed to ensure licensed nurse delegation for dialing insulin dosage on insulin pens to certified medication aides.
26-41-104 (d) Disaster and Emergency Preparedness: The administrator failed to ensure quarterly review of the emergency management plan with employees and residents.
26-41-207 (b)(5-6) (c) Infection Control Policies: The administrator failed to ensure compliance with tuberculosis testing guidelines for residents and new employees, including lack of 2-step TB skin tests and annual TB questionnaires.
Report Facts
Census: 19
Sampled residents: 3
Sampled medication aides: 4
New employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported lack of training and delegation for blood glucose testing, insulin pen dialing, emergency plan reviews, and tuberculosis testing issues. | |
| Licensed nursing staff B | Licensed nursing staff | Reported TB testing should be in resident charts and noted quality assurance efforts. |
| Certified staff D | Certified medication aide | Lacked evidence of licensed nurse delegation for blood glucose testing and insulin pen dialing; lacked proper TB testing. |
| Certified staff E | Certified medication aide | Lacked evidence of licensed nurse delegation for blood glucose testing and insulin pen dialing; lacked proper TB testing. |
| Certified staff F | Certified medication aide | Lacked evidence of licensed nurse delegation for blood glucose testing and insulin pen dialing. |
| Housekeeping staff C | Lacked timely TB testing according to guidelines. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 25, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-01-09.
Findings
All deficiencies have been corrected as of the alleged compliance date of 2018-02-08, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Feb 8, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies during a regulatory inspection.
Findings
The Plan of Correction addresses multiple deficiencies including resident accommodations for smoking during inclement weather, nutritional care plan updates, bathing preferences, skin integrity documentation, fall prevention and transfer techniques, medication monitoring including expired medications and black box warnings, kitchen sanitation issues, infection control practices, and facility maintenance such as flooring repairs.
Deficiencies (12)
F558-D: Resident #2's smoking privileges require accommodations during inclement weather, including provision of appropriate clothing and development of a shelter/windbreak.
F657-D: Resident #9's nutritional care plan was updated to reflect current problems and interventions; audits will ensure care plans are reviewed and revised timely.
F676-D: Bathing preferences will be re-evaluated for all residents, with nursing staff re-educated on respecting resident choices and documenting refusals.
F684-D: Bruising assessments and documentation for Resident #26 will be ongoing; nursing staff received counseling and re-education on skin integrity documentation.
F689-D: Resident #26 received re-education on transfer techniques; fall audits will be conducted to ensure timely root cause analysis and intervention implementation.
F692-D: Resident #9's order for 2 Cal QID was entered; staff re-educated on acting upon Registered Dietician recommendations timely.
F755-E: Expired medications for residents #1, 4, 8, and 15 were removed from the medication supply and disposed of.
F756-D: Resident #13 had TSH labs ordered and black box warning information added to clinical record; staff re-educated on medication monitoring requirements.
F757-D: Resident #13's medication lab monitoring and black box warnings will be audited; nursing staff re-educated on monitoring lab values.
F812-F: Multiple kitchen sanitation issues identified including food debris, grease, and dust on equipment and surfaces; cleaning schedule revised and monitoring increased.
F880-F: Laundry bins replaced; personal care items labeled and stored properly; staff re-educated on infection control practices.
F921-E: Kitchen flooring will be repaired and replaced as needed; maintenance director will monitor floor integrity monthly.
Report Facts
Deficiencies cited: 13
Monitoring frequency: 3
Audit frequency: 8
Audit frequency per week: 3
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 12
Date: Jan 9, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation covering multiple complaint investigations and annual review.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs related to smoking during inclement weather, failure to revise care plans timely, failure to provide timely bathing services, failure to monitor bruising and falls, failure to ensure safe transfers, failure to follow dietitian recommendations, failure to monitor expired medications, failure to identify medication irregularities, failure to maintain sanitary food preparation and storage, failure to maintain infection control practices, and failure to maintain a safe and sanitary kitchen environment.
Deficiencies (12)
CFR 483.10(e)(3) The facility failed to provide reasonable accommodation of resident #2's smoking needs during inclement weather due to lack of shelter and restrictive policies.
CFR 483.21(b)(2) The facility failed to review and revise care plans for residents #9 and #236 to reflect current nutritional needs and fall risk interventions.
CFR 483.24(a) The facility failed to provide timely bathing services to resident #237, who lacked showers for multiple days.
CFR 483.25 Quality of care was deficient as the facility failed to monitor bruising for resident #26, resulting in unmonitored bruises of unknown origin.
CFR 483.25(d) The facility failed to prevent accidents by not implementing fall interventions for resident #236 and failing to use a gait belt during transfer of resident #26.
CFR 483.25(g) The facility failed to follow up on dietitian recommendations for resident #9, resulting in continued weight loss without appropriate nutritional intervention.
CFR 483.45(a)(b) The facility failed to monitor and dispose of expired medications for residents #1, #4, #8, and #15, resulting in expired medications present on medication carts.
CFR 483.45(c) The facility failed to ensure the consultant pharmacist identified irregularities related to annual thyroid lab work and failed to identify a black box warning for Lorazepam for resident #13.
CFR 483.45(d) The facility failed to follow annual lab orders for thyroid medication monitoring and failed to identify a black box warning for Lorazepam for resident #13 receiving opioids.
CFR 483.60(i) The facility failed to maintain sanitary food preparation and storage areas, with multiple areas of food debris, grease, dust, and unclean equipment in the kitchen.
CFR 483.80 The facility failed to maintain laundry equipment, store resident care equipment properly, and ensure hand hygiene after glove use and between resident contacts, increasing infection risk for residents #2, #3, #9, #13, and #21.
CFR 483.90(i) The facility failed to maintain kitchen flooring in a safe, sanitary, and functional condition, with cracked, missing, and heavily soiled linoleum flooring posing safety and sanitation concerns.
Report Facts
Resident census: 32
Weight loss percentage: 3.14
Weight loss percentage: 6.61
Weight loss percentage: 12.78
Bruise size cm: 4.1
Bruise size cm: 7.2
Bruise size cm: 2.1
Bruise size cm: 2.3
Bruise size cm: 2.4
Bruise size cm: 3.5
Medication expiration dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Direct Care Staff | Named in failure to wash hands after glove use and failure to use gait belt during transfer |
| Staff K | Direct Care Staff | Named in failure to wash hands after glove use |
| Staff L | Direct Care Staff | Named in failure to wash hands after glove use and feeding resident |
| Staff G | Direct Care Staff | Named in feeding resident and awareness of bruises |
| Staff H | Dietary Staff | Named in kitchen sanitation and nutrition risk meeting |
| Staff D | Licensed Nursing Staff | Named in hand hygiene and resident care |
| Staff C | Licensed Nursing Staff | Named in hand hygiene and medication monitoring |
| Staff B | Administrative Nursing Staff | Named in hand hygiene, fall care plan, and medication monitoring |
| Staff O | Direct Care Staff | Named in medication cart monitoring |
| Staff P | Direct Care Staff | Named in resident care and fall history |
| Staff Q | Direct Care Staff | Named in resident care and fall history |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 3, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented in the facility's plan of correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.12(a)(3)(4)(c)(1)-(4), 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2), and 483.25(d)(1)(2)(n)(1)-(3) were corrected by 03/22/2017.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 3, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.12(a)(3)(4)(c)(1)-(4), 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2), and 483.25(d)(1)(2)(n)(1)-(3) were corrected by 03/22/2017.
Deficiencies (3)
Regulation 483.12(a)(3)(4)(c)(1)-(4) deficiency was corrected as of 03/22/2017.
Regulation 483.10(c)(2)(i-ii,iv,v)(3) and 483.21(b)(2) deficiency was corrected as of 03/22/2017.
Regulation 483.25(d)(1)(2)(n)(1)-(3) deficiency was corrected as of 03/22/2017.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Mar 22, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Findings
The plan addresses fall prevention and abuse/neglect investigation deficiencies. It outlines corrective actions including review and update of care plans, root cause analysis of falls, staff in-service training, and ongoing monitoring by the Director of Nursing and Quality Assurance Committee.
Deficiencies (3)
F225-E: Residents #1 and #4 are no longer at the facility. Care plans for residents #2 and #3 were reviewed and updated to prevent reoccurring falls. Incidents are reviewed to rule out abuse or neglect and ensure fall prevention interventions are implemented.
F280-E: Care plans and progress notes for residents #2 and #3 were reviewed to ensure root cause analysis of falls was completed and interventions were implemented. Staff were in-serviced on procedures to perform root cause analysis and investigate incidents.
F323-G: Medical records for residents #2 and #3 were reviewed to confirm root cause analysis and timely care plan updates. Staff were in-serviced on procedures to ensure interventions are implemented timely after each fall.
Report Facts
Plan of Correction completion date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurala Lachman | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: Mar 1, 2017
Visit Reason
Complaint investigation #111819 regarding allegations of abuse, neglect, and failure to thoroughly investigate falls and report to the state agency.
Complaint Details
Complaint investigation #111819 regarding failure to investigate and report falls, and failure to implement fall prevention interventions.
Findings
The facility failed to thoroughly investigate falls for four sampled residents, failed to report a fall with head injury requiring sutures to the state agency, and failed to revise care plans and implement interventions to prevent further falls. The facility also failed to provide adequate supervision and assistive devices to prevent repeated falls, resulting in injury and hospitalization.
Deficiencies (3)
483.12(a)(3)(4)(c)(1)-(4) The facility failed to thoroughly investigate falls for four sampled residents and failed to report a fall with head injury requiring sutures to the state agency.
483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) The facility failed to review and revise care plans following falls for four residents, including failure to implement interventions to prevent further falls.
483.25(d)(1)(2)(n)(1)-(3) The facility failed to ensure adequate supervision and assistive devices to prevent repeated falls for residents, resulting in injury requiring hospitalization and sutures.
Report Facts
Resident census: 34
Fall risk assessment scores: 21
Fall risk assessment scores: 28
Fall risk assessment scores: 20
Fall risk assessment scores: 19
Fall risk assessment scores: 3
Fall risk assessment scores: 14
Fall risk assessment scores: 15
Laceration size: 1.5
Hematoma size: 2.5
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 1, 2017
Visit Reason
An abbreviated 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 a level of actual harm that is not immediate jeopardy. Based on these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.
Report Facts
Denial of payment effective date: Mar 23, 2017
Compliance deadline: Sep 1, 2017
Civil Money Penalty minimum amount: 5000
IDR submission deadline: 10
Hearing request deadline: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as contact for questions and Informal Dispute Resolution process |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 1, 2017
Visit Reason
An abbreviated 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 a level of actual harm that is not immediate jeopardy, requiring corrections. Based on these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.
Report Facts
Denial of payment effective date: Mar 23, 2017
Timeframe for substantial compliance: 6
Civil Money Penalty minimum amount: 5000
IDR submission deadline: 10
Hearing request deadline: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as contact for questions and IDR process |
| Lisa Hauptman | CMS Contact | Contact for questions regarding the matter |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Date: Jul 13, 2016
Visit Reason
The inspection was conducted as an investigation of complaint #102286 regarding the facility's failure to provide adequate supervision to a resident who eloped from the facility.
Complaint Details
The complaint investigation found the resident eloped on 6/22/16, was found by staff uninjured, and the facility had not identified the resident as an elopement risk or included this in the care plan. The resident scored very low risk on admission wandering risk tool. The facility's elopement prevention measures were inadequate and corrective actions were implemented after the incident.
Findings
The facility failed to provide adequate supervision for one cognitively impaired resident who exited the facility without staff knowledge and ambulated approximately two-tenths of a mile in a residential area with a 20 mph speed limit and high temperature. The resident was found uninjured and the facility's elopement prevention policies and care planning were inadequate.
Deficiencies (1)
483.25(h) The facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping approximately two-tenths of a mile from the facility without staff knowledge. This placed the resident in immediate jeopardy.
Report Facts
Resident census: 28
Temperature: 93.9
Distance eloped: 0.2
Speed limit: 20
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 13, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation for Winfield Senior Living.
Complaint Details
This plan of correction is linked to a complaint investigation for Winfield Senior Living, revised on 07/13/2016.
Findings
The plan addresses past noncompliance issues identified under tags F0000 and F323-J, for which no new plan of correction was required.
Deficiencies (2)
Tag F0000 relates to past noncompliance with no plan of correction required.
Tag F323-J relates to past noncompliance with no plan of correction required.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 30, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) was corrected by the revisit date of 06/30/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 06/30/2016.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 30, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that the previously reported deficiencies have been corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Jun 15, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#100874) regarding the facility's supervision and safety measures for residents at risk of elopement.
Complaint Details
The complaint investigation #100874 found the facility did not adequately supervise a resident with Alzheimer's disease who eloped twice. The facility failed to report the incident properly and did not monitor intervention effectiveness in a timely manner.
Findings
The facility failed to provide adequate supervision for one resident with Alzheimer's disease who exited the building on two occasions without staff knowledge. The facility also failed to monitor the effectiveness of interventions and failed to report the elopement incident as required by policy.
Deficiencies (1)
483.25(h) The facility failed to provide adequate supervision for one resident who exited the facility twice without staff knowledge, despite being identified as an elopement risk with severe cognitive impairment.
Report Facts
Resident census: 31
Sampled residents for elopement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative licensed nurse B | Licensed Nurse | Documented verbal corrective action for licensed charge nurse C for failure to report elopement |
| Licensed charge nurse C | Licensed Nurse | Failed to report or document resident's elopement as required by facility policy |
| Administrative staff A | Reported facility interventions following elopement and acknowledged hospital failed to inform facility of resident's prior elopement |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 15, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found a 'D' 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, resulting in a finding of substantial compliance effective June 30, 2016.
Deficiencies (1)
The facility had a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 31, 2016
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to resident safety and elopement prevention.
Findings
Resident #01 was transferred to a locked memory unit facility after concerns about elopement. The facility reviewed residents with high wandering risk scores and updated policies and staff training to prevent elopement.
Deficiencies (1)
F323-D: Resident #01 was transferred to a locked memory unit on 5/31/2016. The facility reviewed residents with wandering assessment scores of 9 or higher to ensure care plans include adequate supervision and protective devices.
Report Facts
Wandering assessment score threshold: 9
Compliance date: Jun 30, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Diehl | Executive Director | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 5, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies have been corrected as of the revisit date. Corrections were completed for multiple regulatory requirements listed with their respective codes.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 5, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.15(h)(2), 483.25(l), and 483.60(c) have been corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 29, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The plan addresses environmental concerns including odor and soiled furniture, and medication management issues related to antipsychotic use and monitoring with AIMS assessments and blood pressure parameters.
Deficiencies (3)
F-253 D: The resident's soiled chair was removed and the room was deep cleaned and steam cleaned. A system of daily resident checks for odor was implemented and results will be reported quarterly to the QAPI Committee.
F-329 D: The facility will assess AIMS scores for antipsychotic use and report abnormal blood pressures to physicians. Nursing management will monitor compliance and report monthly to the QAPI Committee.
F-428 D: The facility will follow consultant pharmacist recommendations to provide AIMS assessments for antipsychotic use. Nursing management will monitor compliance and report monthly to the QAPI Committee.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 20, 2016
Visit Reason
A Health survey was conducted to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective May 5, 2016.
Deficiencies (1)
The survey identified isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the plan of correction acceptance letter. |
Inspection Report
Re-Inspection
Census: 25
Deficiencies: 3
Date: Apr 20, 2016
Visit Reason
The visit was a health resurvey to assess compliance with previously identified deficiencies and to verify correction of issues.
Findings
The facility failed to maintain sanitary housekeeping in one resident's room due to a persistent urine odor. Additionally, the facility failed to properly monitor and report irregular blood pressures and did not follow up on consultant pharmacist recommendations for AIMS assessments related to antipsychotic medication use for one resident.
Deficiencies (3)
F 253 Housekeeping and maintenance services were inadequate as one resident's room had a persistent strong urine odor due to a contaminated cloth recliner brought from assisted living.
F 329 The facility failed to assess the AIMS score for antipsychotic use and did not report blood pressures outside defined parameters for one resident, risking adverse medication reactions.
F 428 The facility did not follow up on the consultant pharmacist's recommendation to provide an AIMS assessment for a resident on long-term antipsychotic medication to prevent adverse reactions.
Report Facts
Deficiencies cited: 3
Resident census: 25
Residents reviewed: 11
Blood pressure readings out of range: 3
Behavior symptom log days: 15
Inspection Report
Life Safety
Deficiencies: 0
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 with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 20, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as of the revisit date.
Findings
The report confirms that the deficiencies previously cited under regulations 483.25(c) and 483.75(g) were corrected by 09/15/2015.
Deficiencies (2)
Regulation 483.25(c): Previously cited deficiency was corrected by 09/15/2015.
Regulation 483.75(g): Previously cited deficiency was corrected by 09/15/2015.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 20, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 were corrected as of 10/10/2015, with no uncorrected deficiencies noted at the time of this revisit.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Oct 10, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies including housekeeping and maintenance issues, discontinuation of hot pack use for pain management, care plan revisions for residents with weight loss, monitoring of bowel movements and PRN medication administration, and disposal of expired medications.
Deficiencies (8)
F253-E: The facility will provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in identified halls, addressing issues such as slow draining sinks, peeling wallpaper, lime build-up, and damaged fixtures.
F279-D: Hot packs are no longer used for pain management for any residents, and the facility has removed all hot packs and hydroculators from circulation.
F280-D: The facility will review and revise care plans for residents experiencing significant weight loss to ensure they follow current physician orders and resident wishes, with monitoring by the Director of Nursing and interdisciplinary team.
F309-D: Hot packs are no longer used for pain management, and nursing staff will be re-educated to ensure physician orders are obtained prior to treatments, with monitoring during clinical meetings.
F325-D: The facility will review and revise care plans for residents with weight loss, monitor provision of supplemental shakes, and have the QAPI Committee oversee effectiveness of interventions.
F329-D: The facility will monitor residents' bowel movements and administer PRN medications as ordered, with interdisciplinary team review and QAPI Committee monitoring to sustain solutions.
F428-D: The facility will monitor residents' bowel movements and PRN medication administration, with pharmacy consultant involvement and QAPI Committee oversight.
F431-E: No residents were specifically identified; the facility disposed of all expired medications and will have the Central Supply Clerk monitor medication expiration weekly with monthly QAPI Committee reporting.
Report Facts
Corrective action completion date: Oct 10, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J Stephenson | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 8
Date: Sep 21, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements related to housekeeping, care planning, medication administration, and other care services.
Complaint Details
The inspection included a complaint investigation identified as #89034, focusing on housekeeping, care planning, medication administration, and resident treatment issues.
Findings
The facility failed to maintain a sanitary environment, develop individualized care plans, provide appropriate treatment with warm moist packs, monitor nutritional supplement intake, ensure adequate bowel monitoring and medication administration, and properly manage medication expiration dates.
Deficiencies (8)
F 253 Housekeeping & maintenance services were inadequate, with issues such as slow draining sinks, debris in shower rooms, peeling wallpaper, cracked light covers, chipped paint, and dirty beauty shop areas.
F 279 The facility failed to develop an individualized comprehensive care plan for a resident regarding the use of a warm moist pack for pain relief.
F 280 The facility failed to review and revise the plan of care to ensure monitoring and implementation of nutritional supplement intake for a resident with weight loss.
F 309 The facility failed to provide appropriate treatment and obtain physician orders prior to use of a warm moist pack, resulting in a resident sustaining a first-degree burn.
F 325 The facility failed to ensure adequate monitoring and implementation of nutritional supplement shakes for a resident with weight loss when meal intake was below 50%.
F 329 The facility failed to monitor bowel movements and administer PRN medications as ordered for a resident with constipation.
F 428 The facility consultant failed to identify irregularities in drug regimen related to bowel monitoring and use of PRN medications for constipation for a resident.
F 431 The facility failed to monitor expiration dates of stock medications and discard expired medications in a timely manner.
Report Facts
Census: 28
Resident sample size: 15
Weight measurements: 131
Weight measurements: 97
Weight measurements: 104.8
Burn size: 3.7
Burn size: 6.3
Burn size: 4.5
Burn size: 8.2
Expired medication count: 12
Inspection Report
Enforcement
Deficiencies: 0
Date: Sep 21, 2015
Visit Reason
The 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 'E' level. As a result, a denial of payment for new Medicare and Medicaid admissions was imposed effective September 29, 2015, until the facility achieves substantial compliance or the provider agreement is terminated.
Report Facts
Denial of Payment Effective Date: Sep 29, 2015
Denial of Payment Duration: 6
Civil Money Penalty Minimum: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator |
| Audrey Sunderraj | Director | Named as contact for informal dispute resolution |
Inspection Report
Enforcement
Deficiencies: 0
Date: Sep 21, 2015
Visit Reason
A Health survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies in the facility to be at 'E' level. As a result, a denial of payment for new Medicare and Medicaid admissions will be imposed effective September 29, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Report Facts
Denial of Payment Effective Date: Sep 29, 2015
Denial of Payment Duration: 6
Civil Money Penalty Minimum Amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter as Enforcement Coordinator |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 15, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Winfield Senior Living Community.
Findings
The plan addresses skin condition assessments and staff training on shower sheets and skin assessments. It also clarifies the role of a corporate consultant pending licensure approval.
Deficiencies (2)
F314-G: Residents #3 and #4 were assessed for additional skin conditions. All residents with potential skin conditions were assessed by a licensed nurse. Nursing staff received training on completing shower sheets and weekly skin assessments. CNAs will complete shower sheets with each bath/shower and report skin issues to licensed nurses. The Director of Nursing will audit shower sheets and skin assessments regularly.
F499-E: A corporate consultant will only serve in a consulting role for the LNHA and DON and will not practice nursing until properly licensed in Kansas.
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 26, 2015
Visit Reason
The facility underwent an Abbreviated survey on August 19, 2015, and a Life Safety Code survey on August 26, 2015, to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The Life Safety Code survey found widespread 'F' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit a plan of correction and faces recommended remedies including denial of payments and possible termination of provider agreement if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for widespread 'F' level deficiencies under the Life Safety Code with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Date of Abbreviated survey: Aug 19, 2015
Date of Life Safety Code survey: Aug 26, 2015
Effective date for denial of payments: Nov 19, 2015
Effective date for provider agreement termination: Feb 19, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter and coordinated survey results |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 26, 2015
Visit Reason
The facility underwent an Abbreviated survey on August 19, 2015, and a Life Safety Code survey on August 26, 2015, to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The Life Safety Code survey found widespread 'F' level deficiencies with 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 had widespread 'F' level deficiencies in Life Safety Code compliance with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Denial of payments effective date: Nov 19, 2015
Provider agreement termination date: Feb 19, 2016
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process and recipient of IDR requests. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey results. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Aug 19, 2015
Visit Reason
Complaint investigation #90257 regarding the facility's failure to provide necessary treatment and services to prevent and heal pressure sores in residents.
Complaint Details
Complaint investigation #90257 focused on pressure ulcer treatment and staffing qualifications. The complaint was substantiated based on findings of inadequate pressure ulcer care and unlicensed consultant nursing staff.
Findings
The facility failed to provide adequate treatment and services to promote healing and prevent new pressure sores for two residents, resulting in a Stage II pressure ulcer progressing to an unstageable ulcer for one resident and a facility-acquired Stage II pressure ulcer for another. Additionally, the facility failed to employ qualified nursing staff with a current Kansas nursing license.
Deficiencies (2)
483.25(c) The facility failed to provide necessary treatment and services to promote healing and prevent new pressure sores for 2 of 3 residents reviewed, including inadequate wound assessment and inconsistent use of preventive devices.
483.75(g) The facility failed to employ consultant staff with a current Kansas nursing license as required by state law.
Report Facts
Census: 32
Pressure ulcer measurements: 3
Pressure ulcer measurements: 1
Braden scores: 13
Braden scores: 12
Braden scores: 13
Braden scores: 11
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 19, 2015
Visit Reason
An abbreviated 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 deficiency to be at a 'G' level related to pressure ulcers. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended due to noncompliance.
Deficiencies (1)
F314: The facility was noncompliant with requirements related to pressure ulcers. Corrective actions are needed to prevent avoidable pressure ulcers and ensure appropriate care to prevent increased complexity of existing ulcers.
Report Facts
Denial of Payment effective date: Nov 19, 2015
Termination recommendation date: Feb 19, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 22, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Winfield Senior Community ALF.
Findings
The plan addresses resolved and ongoing issues including wound care for Resident #3 and updated service plans and monitoring for Resident #5 related to medication that can increase bruising. The facility established documentation and training protocols for Certified Medication Aides and Licensed Nurses to improve incident reporting and resident monitoring.
Deficiencies (2)
S0000 The statement of Deficiency will be presented at the next QAA for review and follow up auditing of the plan of correction. Preparation and execution of this response does not constitute admission of agreement with the deficiencies.
S3171-D Resident #3 wound is resolved. Resident #5 service plan was updated to include use of medication that can cause increased bruising and skin will be monitored weekly with interventions as needed.
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 22, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
The report documents that previously identified deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-41-204 (i) deficiency previously cited was corrected by 05/22/2015.
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 22, 2015
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously identified deficiency under regulation 26-41-204 (i) was corrected as of the revisit date.
Deficiencies (1)
Regulation 26-41-204 (i) deficiency was corrected by the revisit date of 2015-05-22.
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 2
Date: Apr 29, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#85108) to evaluate the facility's compliance with health care service standards following reported incidents involving resident injuries.
Complaint Details
Complaint investigation #85108 found substantiated deficiencies related to inadequate nursing assessments and failure to monitor resident injuries and bruising.
Findings
The facility failed to provide adequate nursing assessments for two residents following injuries, including delayed wound assessment and lack of routine skin assessments for bruising. Licensed nursing staff did not perform timely or thorough evaluations despite resident injuries and medication risks.
Deficiencies (2)
26-41-204 (i) Health Care Services Standards of Practice: The facility failed to provide adequate nursing assessments for 2 of 4 residents reviewed following injuries, including a 10-day delay in wound assessment for resident #3 after a cut from a steak knife.
The facility failed to ensure routine skin assessments for resident #5 who had multiple bruises with various fading shades, and nursing notes lacked documentation of these bruises from 03/01 to 04/24/15.
Report Facts
Resident census: 12
Wound size: 1.4
Bruising diameter: 2
Medication dosage: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Acknowledged lack of wound assessment and unawareness of resident bruising |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 28, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report documents that all previously identified deficiencies listed on the CMS-2567 have been corrected as of 03/23/2015.
Report Facts
Deficiency corrections: 13
Inspection Report
Plan of Correction
Deficiencies: 13
Date: Mar 23, 2015
Visit Reason
This document is a Plan of Correction submitted by Winfield Senior Living Community in response to deficiencies cited during a prior inspection. It outlines corrective actions and training to achieve substantial compliance.
Findings
The plan addresses multiple deficiencies including staff training on root cause analysis, resident fund management, maintenance and housekeeping issues, fall prevention, infection control, medication administration, and documentation compliance. The facility commits to ongoing monitoring and quality assurance activities.
Deficiencies (13)
F0000: The facility will review and discuss the plan of correction actions with the Quality Assurance committee and provide staff training on Root Cause Analysis by March 24, 2015.
F159-F: The facility changed the resident funds bank account to an interest-bearing account and will pay back interest from Nov 1, 2014 to Feb 25, 2015 by March 23, 2015.
F253-E: Incontinent briefs were removed from the bathroom floor, bathroom tiles secured, and maintenance and housekeeping issues addressed by March 23, 2015.
F280-D: Resident 8 was moved closer to the nurses station; fall prevention equipment was adjusted and staff trained on Care Plan Change forms by March 23, 2015.
F309-D: Guidelines for neurological flow sheets after unwitnessed falls were implemented and staff trained by March 6, 2015.
F315-D: Staff will be educated on catheter care and infection prevention; infection logs will be maintained and reviewed weekly.
F322-D: Licensed staff will be educated on treatment guidelines to prevent aspiration and dehydration for residents with feeding tubes; compliance will be monitored monthly.
F323-D: Wheelchair brakes were fixed; fall incident packets updated; weekly wheelchair and walker checks implemented by nursing aides.
F329-D: Weekly blood pressure guidelines implemented; medication records updated; staff educated; audits performed weekly and monthly.
F332-D: Licensed nurses will educate Certified Medication Aides on medication administration and complete competency checklists every 6 months.
F333-D: Medication audit completed; Prozac discontinued for resident #8; new guidelines prevent agency nurses from final medication checks; staff trained.
F356-C: Staff educated on completing required staffing forms; forms will be maintained and monitored weekly for 18 months.
F425-D: Licensed staff educated on pharmacy medication ordering guidelines; nurses will communicate with pharmacy and physicians regarding unavailable medications.
Report Facts
Date of plan completion: Mar 23, 2015
Date of staff training on Root Cause Analysis: Mar 19, 2015
Back interest period: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Goodman | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 0
Date: Feb 26, 2015
Visit Reason
The inspection 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 deficiency in the facility to be an 'F' level. Enforcement remedies including denial of payment for new Medicare admissions were imposed due to failure to achieve substantial compliance.
Report Facts
Denial of payment effective date: May 26, 2015
Termination recommendation date: Aug 26, 2015
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 12
Date: Feb 26, 2015
Visit Reason
The inspection was conducted as a health facility resurvey and complaint investigations #83777 and #84093.
Complaint Details
The inspection included complaint investigations #83777 and #84093.
Findings
The facility was found deficient in multiple areas including management of residents' personal funds, housekeeping and maintenance services, care planning and revision, fall prevention and monitoring, neurological assessments after falls, urinary catheter care, feeding tube management, medication administration, and nurse staffing postings.
Deficiencies (12)
F159: The facility failed to manage residents' personal funds properly, including failure to deposit funds in an interest bearing account and use of residents' trust fund monies for petty cash.
F253: The facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 2 of 3 resident hallways.
F280: The facility failed to review and revise care plans for 2 residents who experienced falls, and failed to implement new interventions to prevent further falls.
F309: The facility failed to assess neurological status following 3 of 6 falls with head injury or unwitnessed falls for a resident.
F315: The facility failed to provide urinary catheter care to prevent urinary tract infections for a resident with an indwelling catheter, including allowing catheter tubing to contact the floor.
F322: The facility failed to provide appropriate treatment and services to prevent aspiration and dehydration for a resident with a feeding gastrostomy tube, including failure to check tube placement prior to medication administration and inadequate water flushes.
F323: The facility failed to provide adequate supervision and assistive devices to prevent repeated falls for 2 residents, including failure to repair a broken wheelchair brake and failure to ensure functioning fall alarms.
F329: The facility failed to ensure adequate blood pressure monitoring related to antihypertensive medication administration for a resident.
F332: The facility failed to maintain medication administration error rates below 5%, with 2 medication errors observed for a resident, including crushing a medication that should not be crushed and failure to check blood pressure prior to administration.
F333: The facility failed to ensure a resident was free of significant medication errors, including failure to administer ordered Prozac for 24 days and administering potassium without proper orders.
F356: The facility failed to maintain posted daily nurse staffing information for at least the last 18 months as required by state law.
F425: The facility failed to provide pharmaceutical services to meet the needs of residents, including failure to provide medications in a timely manner and failure to ensure pain medication availability and administration as ordered.
Report Facts
Resident census: 30
Residents with funds managed: 29
Total monies in trust fund: 14226.85
Petty cash fund amount: 200
Fall risk score: 25
Fall risk score: 28
Fall risk score: 15
Potassium level: 6.1
Medication administration opportunities observed: 29
Medication errors: 2
Medication error rate: 6.89
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 26, 2015
Visit Reason
The licensure resurvey was conducted to assess compliance for continued program participation and renewal of the facility's license.
Findings
The inspection resulted in a finding of no deficiency citations.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 9, 2015
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread with no immediate jeopardy but potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Apr 9, 2015
Provider agreement termination date: Jul 9, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Goodman | Administrator | Named as facility administrator in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
| Joe Ewert | Commissioner | Copied on the letter as KDADS Commissioner. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 2, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the Plan of Correction.
Findings
The report confirms that deficiencies previously reported under regulations 483.20(d)(3), 483.10(k)(2), and 483.25 were corrected by the revisit date of 09/02/2014.
Deficiencies (2)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiencies were corrected as of 09/02/2014.
Regulation 483.25: Previously cited deficiencies were corrected as of 09/02/2014.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 2, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection of the nursing facility.
Findings
The plan addresses updating dental assessments for Resident #19, scheduling dental visits, educating licensed nurses on oral/dental assessments and short term care plan approaches, and implementing audits to ensure compliance. The facility aims to achieve substantial compliance by September 2, 2014.
Deficiencies (2)
F280-D: Resident #19 will have an updated dental assessment and be scheduled to see a dentist. Licensed nurses will be educated on oral/dental assessments, which will be implemented for all residents with quarterly follow-ups and audits.
F309-D: Resident #19 will have an updated dental assessment and be scheduled to see a dentist. Licensed nurses will be educated on oral/dental assessments and short term care plan approaches, with audits to monitor compliance and follow-up.
Report Facts
Plan of Correction completion date: Sep 2, 2014
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 2, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.
Deficiencies (2)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiencies were corrected by 09/02/2014.
Regulation 483.25: Previously cited deficiencies were corrected by 09/02/2014.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 2
Date: Aug 5, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with care planning and treatment requirements following prior deficiencies.
Findings
The facility failed to review and revise the care plan for a resident with an oral wound and failed to provide timely assessment and treatment for the oral lesion. The resident had a 3 cm sore on the upper gum related to denture use, which was not adequately addressed in the care plan or medical record.
Deficiencies (2)
F 280: The facility failed to review and revise the plan of care for a resident with an oral wound, lacking interventions for assessment and treatment of the wound and denture management.
F 309: The facility failed to provide adequate assessment and timely treatment for an oral lesion in a resident, despite documented complaints and observations of a sore and swelling.
Report Facts
Resident census: 37
Sampled residents: 16
Oral wound size: 3
BIMS score: 15
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed nursing staff | Named in relation to care plan compliance and wound assessment |
| Staff B | Administrative nursing staff | Provided information about wound assessment and instructions to resident |
| Staff C | Licensed nursing staff | Mentioned regarding knowledge of resident's mouth sores |
| Direct care F | Reported on resident's independence and oral care habits | |
| Direct care G | Reported on resident's mouth sore and denture use | |
| Activity staff E | Reported resident's request for dentures and mouth sores |
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 5, 2014
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective September 2, 2014.
Deficiencies (1)
The facility had isolated 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm and no immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 18, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied 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 pattern deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 18, 2014
Provider agreement termination date: Jan 18, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 18, 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 pattern deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Oct 18, 2014
Provider agreement termination date: Jan 18, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 12
Date: Mar 24, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All deficiencies previously reported were corrected by 02/21/2014 as documented in the report. The revisit confirmed the corrective actions were accomplished.
Deficiencies (12)
Regulation 483.15(h)(6) deficiency was corrected by 02/21/2014.
Regulation 483.15(h)(7) deficiency was corrected by 02/21/2014.
Regulations 483.20(d) and 483.20(k)(1) deficiencies were corrected by 02/21/2014.
Regulations 483.20(d)(3) and 483.10(k)(2) deficiencies were corrected by 02/21/2014.
Regulation 483.25(c) deficiency was corrected by 02/21/2014.
Regulation 483.25(d) deficiency was corrected by 02/21/2014.
Regulation 483.25(l) deficiency was corrected by 02/21/2014.
Regulation 483.35(i) deficiency was corrected by 02/21/2014.
Regulations 483.60(a) and (b) deficiencies were corrected by 02/21/2014.
Regulation 483.60(c) deficiency was corrected by 02/21/2014.
Regulation 483.65 deficiency was corrected by 02/21/2014.
Regulation 483.75(o)(1) deficiency was corrected by 02/21/2014.
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Mar 24, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that all previously cited deficiencies identified by regulation or Life Safety Code provisions have been corrected as of February 21, 2014.
Deficiencies (4)
Regulation 26-41-205 (a) (1): Previously cited deficiency corrected as of 02/21/2014.
Regulation 26-41-205 (h): Previously cited deficiency corrected as of 02/21/2014.
Regulation 26-41-206 (e) (1): Previously cited deficiency corrected as of 02/21/2014.
Regulation 28-39-256: Previously cited deficiency corrected as of 02/21/2014.
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Feb 21, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection. It outlines corrective actions to address identified issues and achieve substantial compliance.
Findings
The plan details multiple corrective actions including monitoring and sealing windows, noise reduction measures, individualized toileting and care plans, pressure ulcer prevention, blood glucose monitoring, infection control improvements, and quality assurance training. Audits and staff in-services are scheduled to ensure compliance.
Deficiencies (12)
F257: All windows will be checked and sealed as needed, with temperature monitoring and audits to ensure resident comfort.
F258: Noise reduction measures implemented including protective mats and headset use, with staff monitoring noise levels and documenting concerns.
F279: Individualized toileting plans will be developed and care plans updated to coordinate Hospice services as applicable.
F280: Care plans updated for turning/repositioning and fall prevention; incidents reviewed daily and care plans audited weekly.
F314: Diet Notification Order used to communicate pressure ulcer identification; care alert sheets placed in resident bathrooms and staff educated.
F315: 72-hour voiding patterns will be documented accurately and toileting plans individualized and audited regularly.
F329: Licensed nurses responsible for blood glucose testing and documentation; staff educated and audits conducted to ensure compliance.
F371: Kitchen cleaning procedures updated including discard of loaf pans and added cleaning tasks; staff trained and audits scheduled.
F425: Physician orders for blood sugar and insulin parameters clarified and reviewed with nursing staff; audits conducted weekly and monthly.
F428: Licensed nurses and medication aides educated on blood glucose testing procedures; audits performed weekly and monthly to ensure compliance.
F441: Licensed nurses provide physician orders to Infection Control Nurse who monitors infections and reports monthly; staff educated and audits conducted.
F520: New quality coordinator designated and trained; education on quality assurance provided and QA minutes audited to ensure issue resolution.
Report Facts
Audit frequency: 6
Audit frequency: 1
Staff in-service date: Feb 5, 2014
Compliance date: Feb 21, 2014
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 21, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior inspection of the assisted living facility.
Findings
The plan addresses multiple deficiencies including resident medication self-administration assessments, proper medication refrigerator use, cleaning procedures in the assisted living kitchenette, and water heater temperature adjustments.
Deficiencies (4)
S3175: Residents self-administering medication will be assessed to ensure they can safely and accurately administer medications without assistance. Assessments will be conducted at admission, annually, and upon significant change.
S3215: The refrigerator has been designated for resident medication only, with staff provided a separate refrigerator for food and beverages. Audits will ensure compliance.
S3299: A backsplash will be installed behind the steam table for cleanability. Cleaning procedures for the kitchenette have been updated and staff educated, with ongoing audits planned.
S3420: Water heater temperatures were adjusted to appropriate ranges. Maintenance staff educated and weekly audits planned for one year to ensure compliance.
Inspection Report
Renewal
Census: 15
Deficiencies: 4
Date: Jan 24, 2014
Visit Reason
The inspection was a licensure resurvey to evaluate compliance with state regulations for the assisted living facility.
Findings
The facility failed to complete required assessments for residents self-administering medications, failed to properly store medications securely, failed to maintain sanitary conditions in food storage and preparation areas, and failed to maintain safe water temperatures for residents.
Deficiencies (4)
26-41-205 (a) (1) Self Administration of Medication: The facility failed to complete assessments for self-administration of medications for 2 of 3 residents reviewed prior to allowing self-administration.
26-41-205 (h) Medication Storage: The facility failed to properly store medications in a safe and secure manner for 2 residents, including storing medications in a refrigerator used for staff food.
26-41-206 (e) (1) Facility Food Storage: The facility failed to maintain sanitary conditions in the food service area and failed to store foods in a sanitary manner, including dirty steam table and expired or spoiled food items.
28-39-256 Mechanical Requirements: The facility failed to maintain safe water temperatures, with water temperatures exceeding safe limits in multiple resident areas.
Report Facts
Census: 15
Pre-filled insulin syringes: 15
Food item dates: Jan 4, 2014
Food item dates: Jan 11, 2014
Food item date: Jan 12, 2014
Water temperature: 130
Water temperature: 132.9
Water temperature: 136.8
Water temperature: 132
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 12
Date: Jan 24, 2014
Visit Reason
The inspection was a health resurvey and complaint investigation.
Complaint Details
The inspection was triggered by a complaint investigation #70585.
Findings
The facility failed to maintain comfortable temperature and sound levels, develop comprehensive and individualized care plans, prevent pressure ulcers, monitor medication administration properly, maintain sanitary food service conditions, and maintain an effective infection control program and quality assurance committee.
Deficiencies (12)
F 257: The facility failed to maintain comfortable temperature levels in 3 residents' rooms, with temperatures measured at 66-68°F, below the required 71-81°F range.
F 258: The facility failed to maintain comfortable sound levels on 2 of 3 halls, with residents reporting noise disturbances from roommates and televisions.
F 279: The facility failed to develop individualized care plans for 2 residents, including inadequate toileting plans and lack of coordination with hospice services.
F 280: The facility failed to review and revise care plans for 2 residents to prevent pressure ulcers and falls, including lack of repositioning plans and failure to ensure staff supervision.
F 314: The facility failed to implement effective interventions to prevent and treat pressure ulcers for 1 resident, including failure to reposition timely and apply heel protectors.
F 315: The facility failed to assess and develop an individualized toileting plan for 1 resident with declining continence, lacking complete voiding diaries and reassessments.
F 329: The facility failed to complete blood glucose monitoring as ordered for 1 resident, resulting in unnecessary medication administration.
F 371: The facility failed to maintain a clean and sanitary dietary department, including unclean pans, scoops, utensil drawers, and cereal cart.
F 425: The facility failed to administer insulin as prescribed for 1 resident, including giving insulin despite blood sugar levels below the ordered threshold to hold the dose.
F 428: The facility's pharmacist failed to identify and report drug irregularities related to blood glucose monitoring and insulin administration for 2 residents.
F 441: The facility failed to maintain an infection control program, lacking documentation and trending of infections for several months.
F 520: The facility failed to maintain an effective quality assurance committee that adequately addressed quality deficiencies including pressure ulcers, toileting, and infection control.
Report Facts
Residents present: 32
Residents sampled: 15
Temperature in deficient rooms: 66
Temperature in deficient rooms: 68
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.2
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 2.4
Pressure ulcer measurements: 1.9
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 1.1
Pressure ulcer measurements: 2
Insulin doses given incorrectly: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported on infection control and quality assurance program status. | |
| Administrative nursing staff B | Reported on resident continence decline and insulin administration. | |
| Consultant staff C | Reported on care plan review and infection control monitoring. | |
| Direct care staff Q | Reported on resident care and missing heel protectors. | |
| Direct care staff W | Reported on resident toileting assistance and care. | |
| Licensed nursing staff D | Reported on resident care and insulin administration monitoring. | |
| Licensed nursing staff E | Reported on resident care and insulin administration. | |
| Consultant staff R | Reported on blood sugar monitoring irregularities. | |
| Administrative nursing staff M | Reported on infection control program monitoring. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 28, 2013
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 had been corrected.
Findings
All deficiencies previously reported were corrected as of 08/02/2013, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiencies corrected: 11
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Aug 2, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior deficiency report, outlining corrective actions to address cited deficiencies and ensure compliance.
Findings
The facility has implemented multiple corrective actions including updating care plans, educating staff on behaviors and fall prevention, revising physician order procedures, improving safety checks, enhancing cleaning protocols, and ensuring sufficient staffing. Audits and staff education are planned to ensure ongoing compliance.
Deficiencies (11)
F241: The care plan team met with resident #1's family to update the care plan and educate nursing staff on reporting resident behaviors for intervention updates.
F246: Resident #46 discharged; care plans updated with personal information and nursing staff educated on resident routines and preferences.
F280: Care plans for residents #32 and #33 updated with fall prevention interventions; nursing staff educated and incident reporting procedures reinforced.
F315: Nursing staff re-educated on proper pericare/incontinent care techniques; random audits to ensure competency and compliance.
F323: Facility addressed safety hazards by moving power cords, smoothing partition edges, and ensuring chemicals are locked up; staff trained on new safety procedures.
F329: Blood pressure parameters obtained for resident #45; nurses educated on monitoring and reporting; medication orders reviewed for black box warnings.
F353: Facility committed to providing sufficient staffing based on census and acuity to meet resident needs and maintain housekeeping and maintenance.
F371: Facility improved kitchen cleanliness by purchasing new utensils and updating cleaning schedules for ovens and utensils.
F428: Blood pressure monitoring and medication order procedures revised; audits planned to ensure compliance with drug therapy monitoring.
F441: Sanitizing solution changed and machines reset; maintenance and laundry staff trained on temperature monitoring and chemical usage with auditing.
F465: Medication rooms and various facility areas cleaned and added to weekly cleaning schedules; audits planned to ensure ongoing compliance.
Report Facts
Audit duration: 3
Audit duration: 6
Sanitizing solution concentration: 125
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jul 9, 2013
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiency identified under regulation 26-41-204 (i) with ID prefix S3171 was corrected by 07/03/2013.
Deficiencies (1)
Regulation 26-41-204 (i) deficiency previously cited was corrected by 07/03/2013.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 9
Date: Jul 3, 2013
Visit Reason
Annual survey and comprehensive inspection of Good Samaritan Society - Winfield nursing facility to assess compliance with federal regulations.
Findings
The facility was found deficient in multiple areas including resident dignity, accommodation of preferences, care planning, infection control, medication management, safety, staffing, and environmental sanitation.
Deficiencies (9)
F241: The facility failed to protect the dignity of a resident with severe cognitive impairment who frequently exposed their bare chest without appropriate care plan interventions.
F246: The facility failed to ensure a resident received bathing services according to their personal preferences due to staffing and scheduling issues.
F280: The facility failed to review and revise care plans for multiple residents, including fall prevention, medication monitoring, and dignity concerns, resulting in inadequate interventions.
F315: The facility failed to provide adequate perineal hygiene and timely toileting for incontinent residents, increasing risk of urinary tract infections.
F323: The facility failed to maintain a safe environment free of accident hazards and failed to provide adequate supervision and interventions to prevent repeated falls for residents at risk.
F329: The facility failed to ensure residents remained free from unnecessary drugs by not monitoring blood pressures, black box warnings, and adverse effects of antipsychotic medications.
F441: The facility failed to maintain sanitary conditions in the laundry room, including inadequate water temperature and improper sanitizing of linens, risking infection spread.
F465: The facility failed to maintain a sanitary environment on all halls, including presence of dead bugs, debris, and unclean areas in medication room, utility rooms, and mechanical rooms.
F353: The facility failed to provide sufficient nursing staff to meet the physical, mental, and psychosocial needs of residents, resulting in delayed care and increased risk of falls and other adverse events.
Report Facts
Resident census: 37
Residents selected for review: 24
Blood pressure readings: 11
Nursing staffing counts: 1
Nursing staffing counts: 3
Nursing staffing counts: 4
Dead bugs: 5
Dead crickets: 6
Dead bugs: 6
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 3, 2013
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation regarding failure to conduct proper assessments after resident falls and to ensure neurological checks when necessary.
Findings
The facility failed to conduct assessments to determine the cause of falls and did not perform neurological checks when required. The Plan of Correction outlines new procedures for emergency response, notification, assessment, and updating resident care plans.
Deficiencies (1)
The facility failed to conduct an assessment to determine the cause of a fall and did not ensure neurological checks were done when necessitated by the incident. The assisted living staff will implement new emergency procedures and update resident care plans accordingly.
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 1
Date: Jun 12, 2013
Visit Reason
Complaint investigation #66145 was conducted due to concerns about the facility's failure to provide care and services in accordance with standards of practice, specifically related to falls and post-fall assessments.
Complaint Details
The investigation was triggered by complaint #66145 regarding inadequate care related to falls and failure to conduct proper assessments and interventions.
Findings
The facility failed to assess causes of falls and develop interventions to prevent recurrence for 3 of 4 sampled residents. Resident #1 experienced 4 falls within 24 hours resulting in a hip fracture and head injury without proper neurological checks. Similar failures were noted for residents #2 and #3, with incomplete updates to health service plans and lack of interventions following falls.
Deficiencies (1)
26-41-204 (i) Health Care Services Standards of Practice: The facility failed to provide care by not assessing causes of falls or developing interventions to prevent recurrence for 3 of 4 sampled residents. Resident #1 had 4 falls in 24 hours resulting in a hip fracture and lacked neurological checks after head injury.
Report Facts
Resident census: 15
Falls experienced by resident #1: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Reported on resident falls and care provided | |
| Licensed nursing staff E | Reported on fall assessments and neuro checks | |
| Direct care staff C | Reported observations and resident care related to falls | |
| Direct care staff D | Reported observations and resident care related to falls | |
| Licensed nursing staff F | Reported on resident pain and fall incidents | |
| Physician H | Physician | Provided statements regarding resident fall and care |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 14, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report documents that all previously identified deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 01/08/2013.
Report Facts
Correction completion date: Jan 8, 2013
Follow-up survey completion date: Dec 10, 2012
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 14, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously identified deficiencies listed on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 01/08/2013.
Report Facts
Correction completion date: Jan 8, 2013
Follow-up survey date: Dec 10, 2012
Inspection Report
Plan of Correction
Deficiencies: 22
Date: Jan 8, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior deficiency report, outlining corrective actions to address identified deficiencies and ensure compliance with federal and state regulations.
Findings
The plan details multiple corrective actions including staff education, audits, resident interviews, environmental and safety improvements, care plan updates, and monitoring systems to address issues such as social history documentation, pain management, dialysis monitoring, bowel protocols, hydration, medication management, staffing, and quality assurance processes.
Deficiencies (22)
F0000: The facility will review and take appropriate actions on the statement of deficiencies through the Quality Assurance committee.
F241-D: Social Services Designee will ensure social history forms are completed and lifestyle preferences are addressed in care plans; staff will be educated on responding to resident needs including pain management.
F242-D: A new questionnaire will be used to gather resident preferences; staff will be educated on its use and resident care plans will reflect lifestyle preferences.
F253-E: Housekeeping and environmental issues will be fixed; building foundation concerns will be assessed and addressed to ensure resident safety.
F275-D: MDS Coordinator will complete assessments timely including CAAs for discharged residents; audits will ensure compliance.
F279-D: Care plans will be updated to comprehensively address dialysis, anti-anxiety medication, contractures, and range of motion; nursing staff will be educated on assessments and documentation.
F280-D: The 'getting to know you' form will be completed for all residents and incorporated into care plans; staff education and audits will ensure compliance.
F281-D: Care plans will address use of blood thinning agents; staff will be educated and audits conducted to ensure proper lab draws and documentation.
F309-J: A bowel protocol will be implemented; staff educated on timely assessments, documentation, and physician notification regarding bowel management.
F312-D: Care plans will include individualized personal and oral hygiene needs; staff will be educated and monitored for compliance.
F314-D: Staff will be re-educated on repositioning and use of pressure relieving devices to prevent pressure sores; audits will monitor compliance.
F315-D: Individualized toileting plans will be updated and staff educated on assessment and reporting of continence changes; audits will monitor compliance.
F318-D: Restorative plans will address range of motion and contractures; staff will be educated and audits conducted to ensure compliance.
F323-E: Environmental hazards will be addressed including replacement of carpet and reassessment of resident safety devices; staff education and maintenance audits will be conducted.
F327-D: Hydration orders will be reviewed and revised timely; staff will be educated and audits conducted to ensure resident hydration needs are met.
F329-D: Pharmacy services will be monitored to reduce unnecessary medications; consultant pharmacist will review residents and staff will be educated on following recommendations.
F353-E: Staffing levels will be sufficient to meet resident needs including dialysis, pain management, and hygiene; staff education and resident interviews will monitor compliance.
F356-C: Nurse staffing information will be posted daily; staff will be educated on form completion and audits conducted to ensure compliance.
F425-D: Pharmacy services will ensure timely medication delivery; staff will be educated on procedures to address pharmacy refusals and audits conducted.
F428-D: Pharmacy recommendations will be followed to monitor unnecessary laxatives; consultant pharmacist will review medications monthly and audits conducted.
F490-F: Facility management will ensure dignified care including bowel monitoring, dialysis, pain management, hygiene, repositioning, hydration, and restorative services through staff education and monitoring.
F520-F: Quality Assurance committee will meet monthly to develop and implement plans to correct quality of care and life concerns using continuous survey readiness and quality improvement teams.
Report Facts
Audit frequency: 3
Audit frequency: 9
Audit frequency: 12
Audit frequency: 21
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 4, 2013
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency with regulation 26-41-102 (a) has been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-41-102 (a) deficiency was corrected by the revisit date of 2013-01-04.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 4, 2013
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously identified deficiency with regulation 26-41-102 (a) was corrected as of 2013-01-04.
Deficiencies (1)
Regulation 26-41-102 (a) deficiency was corrected by the revisit date of 2013-01-04.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 4, 2013
Visit Reason
This document is a plan of correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses the need for a sufficient number of direct care or licensed nursing staff in the assisted living area at all times, with staff education and audits to ensure compliance.
Deficiencies (1)
S3245: A sufficient number of direct care staff or licensed nursing staff will be in the assisted living area at all times. Staff will be educated on this requirement and compliance will be monitored through random audits until sustained.
Inspection Report
Census: 41
Deficiencies: 21
Date: Dec 10, 2012
Visit Reason
The inspection was a health resurvey, an extended resurvey, and complaint investigations.
Findings
The facility had multiple deficiencies including failure to provide dignified care, failure to respect resident choices, inadequate housekeeping and maintenance, incomplete comprehensive assessments, lack of comprehensive care plans, insufficient restorative nursing services, unsafe assistive devices, inadequate hydration, and failure to monitor medication regimens properly.
Deficiencies (21)
F241: The facility failed to provide dignified care to resident #55, including timely pain management and response to toileting needs.
F242: The facility failed to respect resident #60's lifestyle choices, including sleep schedule and socialization preferences.
F253: The facility failed to provide adequate housekeeping and maintenance services in multiple resident areas, including hallways, dining room, and activity room.
F275: The facility failed to complete and submit a comprehensive significant change assessment for resident #4 after a fall and hospitalization.
F279: The facility failed to develop comprehensive care plans for residents #5, #52, and #10, including dialysis monitoring, psychotropic medication use, and contracture management.
F280: The facility failed to ensure resident input into care planning for residents #5, #12, and #55, and failed to revise care plans to reflect actual resident needs and preferences.
F281: The facility failed to develop an initial care plan addressing Coumadin use and monitoring for resident #60.
F309: The facility failed to provide adequate care to resident #49 who had no bowel movement for 8 days, resulting in immediate jeopardy; failed to monitor and document bowel movements and laxative effectiveness for multiple residents.
F312: The facility failed to provide oral hygiene and appropriate hand and face washing to resident #58.
F314: The facility failed to prevent pressure ulcers for residents #58 and #6, including failure to provide adequate repositioning and pressure relieving devices.
F315: The facility failed to provide an individualized toileting plan for resident #12 to maintain bladder function.
F318: The facility failed to provide restorative range of motion services to residents #14, #10, and #2 to maintain abilities and prevent decline.
F323: The facility failed to provide safe assistive devices for resident #6 and maintain safe environment in two hallways.
F327: The facility failed to provide adequate hydration to resident #5 per physician's fluid restriction order.
F329: The facility failed to ensure residents' drug regimens were free from unnecessary drugs by inadequate monitoring and documentation of multiple laxatives for residents #14, #15, and #20.
F353: The facility failed to provide sufficient nursing staff to meet residents' physical, mental, and psychosocial needs for 6 of 9 survey days.
F356: The facility failed to post complete nurse staffing data daily, missing second shift staffing information on 3 of 4 days observed.
F425: The facility failed to obtain and administer prescribed medications timely for resident #14, including pain and constipation medications.
F428: The facility failed to follow pharmacy recommendations and monitor effectiveness of bowel medications for residents #14, #15, and #20.
F490: The facility failed to manage the facility to meet residents' needs, as evidenced by multiple deficiencies in care, environment, and staffing.
F520: The facility failed to maintain an effective quality assurance committee that identified and implemented plans to correct quality of care and quality of life deficiencies.
Report Facts
Resident census: 41
Bowel movements: 13
Fluid intake: 1440
Pain wait time: 45
Bed rail looseness: 4
Pressure ulcer size: 3
BIMS score: 13
BIMS score: 15
BIMS score: 6
BIMS score: 4
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff I | Licensed Nurse | Named in pain medication delay and dialysis monitoring for resident #55 and #5 |
| direct care staff M | Direct Care Staff | Named in resident #55 toileting and pain management observation |
| licensed nursing staff E | Licensed Nurse | Named in restorative nursing program and pressure ulcer care |
| licensed nursing staff B | Administrative Nursing Staff | Named in hydration and medication management |
| direct care staff L | Direct Care Staff | Named in restorative nursing and bowel monitoring |
| direct care staff FF | Direct Care Staff | Named in bowel movement monitoring and laxative administration |
| administrative staff A | Administrator | Named in quality assurance committee and staffing |
| licensed nursing staff C | Licensed Nurse | Named in staffing and medication management |
| consultant staff HH | Consultant | Named in pharmacy audit and laxative monitoring |
| direct care staff Q | Direct Care Staff | Named in resident #58 hygiene care |
| direct care staff N | Direct Care Staff | Named in resident #58 hygiene and pressure ulcer care |
Inspection Report
Renewal
Census: 12
Deficiencies: 1
Date: Dec 7, 2012
Visit Reason
The inspection was a licensure resurvey to assess compliance with staffing requirements and other regulatory standards for the assisted living facility.
Findings
The facility failed to maintain adequate staffing at all times, with observations showing insufficient staff coverage on the assisted living side. Administrative staff reported temporary unattended periods when staff left the assisted living area, relying on residents having lifelines or cell phones for emergencies.
Deficiencies (1)
26-41-102 (a) Staff Qualifications Sufficient Staff: The facility failed to maintain adequate staffing to provide services and care in accordance with residents' needs. Observations and record reviews showed insufficient staff coverage, including times when the assisted living side was temporarily unattended.
Report Facts
Census: 12
Staff on duty: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018006 POC M2H811
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for Winfield Senior Living Community's COVID inspection dated 7.13.2020.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a corrective action response to a previous inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018006 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified as State ID N018006.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018006 POC R6SZ11
Visit Reason
This document is a Plan of Correction related to a previous inspection event for the facility.
Findings
No deficiencies or findings are detailed in this document. It serves as a placeholder or record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018006 POC 36SD12
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder for the facility's corrective actions.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018006 POC 4FY811
Visit Reason
This document is a plan of correction related to a prior inspection or regulatory finding for Winfield Senior Living ALF.
Findings
No deficiencies or findings are detailed in this document. It serves as a placeholder or record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N018006 POC B87O12
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the related deficiency report but states no records found.
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