Inspection Reports for Wingfield Skilled Nursing And Rehabilitation Center
NV, 2350 Wingfield Hills Rd, Sparks, NV 89436, United States
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
31 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
337% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
113 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 5, 2024
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey at the facility from December 2, 2024, to December 5, 2024, to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in accurately posting its CMS star rating on its internet website and in ensuring that all employees completed the required Division of Public and Behavioral Health (DPBH) approved cultural competency training. Specifically, the website inaccurately displayed a 5-star rating when the official CMS rating was one star, and one of sixteen sampled employees lacked documented evidence of completing the required cultural competency training.
Deficiencies (2)
Facility failed to ensure the CMS star rating was accurately posted on the facility's internet website, showing a 5-star rating instead of the official 1-star rating.
Facility failed to ensure cultural competency training was completed using a DPBH approved training program for 1 of 16 sampled employees.
Report Facts
Sample size of employees: 16
CMS star rating: 1
CMS star rating incorrectly posted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Activity Director | Named in deficiency for not completing DPBH approved cultural competency training |
| Kaitlyn Modina | Administrator | Confirmed inaccurate CMS star rating posting and responsible for corrective action |
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 10
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as an annual Medicare Recertification and Facility Reported Incident Survey at the facility from 2024-12-02 to 2024-12-05 in accordance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
The survey identified multiple deficiencies related to resident care including inadequate incontinent care, failure to ensure timely medication administration (especially insulin), lack of proper care planning for residents with specific needs such as visual impairment and mental health disorders, insufficient social services follow-up, and improper use and monitoring of bed rails. Several residents reported being ignored or inadequately cared for overnight, resulting in potential psychosocial harm and physical discomfort.
Deficiencies (10)
Resident was not changed overnight resulting in wet brief and bedding causing discomfort and potential psychosocial distress.
Failure to ensure informed consent prior to administration of psychotropic medication.
Failure to submit PASARR Level II screenings for residents with mental health diagnoses.
Failure to provide individualized activities based on resident preferences, especially for visually impaired resident.
Failure to ensure timely and appropriate administration of insulin based on blood sugar levels, including failure to recheck blood sugar prior to insulin administration.
Failure to ensure proper use, monitoring, and care planning related to bed rails, including lack of prior interventions before installation.
Failure to ensure social services follow-up on resident complaints of lack of overnight care.
Failure to ensure proper storage and labeling of medications, including presence of unsecured over-the-counter medication at bedside without orders.
Failure to ensure residents dependent on staff for activities of daily living received timely brief changes and hygiene care.
Failure to ensure pain medication was administered as scheduled, resulting in resident experiencing unrelieved pain.
Report Facts
Census: 113
Sample size: 23
Facility Reported Incidents investigated: 6
Date range of survey: From 2024-12-02 to 2024-12-05
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Named in medication administration deficiency related to insulin administration |
| Director of Nursing (DON) | Director of Nursing | Referenced in multiple findings including medication administration, care planning, and notification of resident complaints |
| Licensed Social Worker (LSW) | Licensed Social Worker | Referenced in social services deficiency related to follow-up on resident complaints |
| Certified Nursing Assistant (CNA) | Certified Nursing Assistant | Referenced in findings related to resident care and incontinent care |
| Activities Director (AD) | Activities Director | Referenced in deficiency related to individualized activities planning |
| Unit Manager | Unit Manager/Licensed Practical Nurse | Referenced in follow-up and notification of resident complaints |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, activities, and safety at Wingfield Skilled Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medication, incomplete care plans for residents' needs such as bed rail use and edema monitoring, unsafe medication administration practices including insulin administration without timely blood sugar checks, inadequate assistance with activities of daily living overnight, failure to provide individualized activities for a visually impaired resident, delayed pain medication refills, and improper medication storage at bedside.
Deficiencies (8)
Failed to ensure a resident gave informed consent prior to administration of psychotropic medication.
Failed to develop and implement a complete care plan addressing resident needs including bed rail use and edema monitoring.
Failed to ensure Licensed Practical Nurse performed safe medication administration by not checking blood sugar levels prior to insulin administration.
Failed to provide adequate overnight brief changes for a resident dependent on staff for Activities of Daily Living.
Failed to ensure a visually impaired resident received individualized activities based on preferences and goals.
Failed to ensure timely refill of pain medication resulting in missed doses.
Failed to ensure resident's blood sugar levels were tested timely prior to insulin administration.
Failed to ensure a resident did not have unsecured over-the-counter medication at bedside without an order.
Report Facts
Residents sampled: 23
Insulin units administered: 4
Medication doses missed: 8
Medication bottle count: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided verbal confirmations and explanations regarding consent, care plans, medication administration, and facility policies | |
| Licensed Practical Nurse (LPN) | Involved in medication administration and provided explanations regarding insulin administration and care plans | |
| Activities Director (AD) | Responsible for personalizing activities care plan and conducting activity interviews | |
| Certified Nursing Assistant (CNA) | Reported resident care concerns including brief changes overnight | |
| Licensed Social Worker | Received resident complaints about overnight care |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 27, 2024
Visit Reason
The inspection was conducted following a complaint and Facility Reported Incident regarding a resident being kicked by another resident, as well as other related concerns including abuse reporting and resident transfer notices.
Complaint Details
The complaint involved Resident #5 being kicked in the leg by Resident #6, resulting in a bruise. The facility failed to protect Resident #5 from abuse and failed to timely report the abuse allegation to the State Agency within the required two-hour timeframe.
Findings
The facility failed to protect a resident from being kicked by another resident, failed to timely report an allegation of abuse to the State Agency within the required timeframe, and failed to include required information in Notices of Transfer or Discharge for multiple residents. Additionally, kitchen equipment temperature logs were not completed daily and hand hygiene supplies were not adequately stocked.
Deficiencies (4)
Failed to protect a resident from being kicked by another resident.
Failed to timely report an allegation of abuse to the State Agency within the required timeframe.
Failed to include reason, effective date, and/or location in Notices of Transfer or Discharge for 8 of 36 discharged residents.
Failed to ensure kitchen equipment temperature logs were completed daily and hand hygiene supplies were available for dietary staff.
Report Facts
Residents affected by abuse deficiency: 1
Residents affected by transfer notice deficiency: 8
Total residents: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Verbalized awareness of the abuse incident and interventions in place for Resident #6. |
| Licensed Social Worker | Licensed Social Worker (LSW) | Received report from Resident #5 about being kicked and provided information about the incident. |
| Regional Director of Social Services | Regional Director of Social Services (RDSS) | Verbalized definition of abuse and reporting process. |
| Administrator | Facility Administrator | Confirmed awareness of abuse allegation and reporting requirements. |
| Discharge Planner | Discharge Planner | Confirmed incomplete Notices of Transfer or Discharge for multiple residents. |
| Food Services Manager | Food Services Manager (FSM) | Confirmed kitchen temperature logs were not up to date. |
| Assistant Food Services Manager | Assistant Food Services Manager | Confirmed lack of paper towels at kitchen hand washing sinks. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
An offsite revisit was conducted on 01/18/24 for all previous deficiencies cited on 12/12/23.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Routine
Deficiencies: 15
Date: Dec 14, 2023
Visit Reason
The inspection was a routine survey of Wingfield Skilled Nursing and Rehabilitation Center to assess compliance with regulatory requirements including grievances, quarterly assessments, care plans, medication administration, infection control, and other resident care standards.
Findings
The facility was found deficient in multiple areas including failure to resolve grievances related to resident food portions, late and inaccurate Minimum Data Set (MDS) assessments, incomplete and inaccurate care plans for pain, wounds, and anemia, medication administration errors including expired medications and improper medication storage, failure to provide meals according to resident preferences, inadequate RN coverage, and incomplete COVID-19 vaccination documentation and education.
Deficiencies (15)
Failure to resolve grievances related to resident #169 not receiving double portions of food as ordered.
Late completion and submission of Minimum Data Set (MDS) assessments for multiple months in 2023.
Inaccurate MDS behavioral section for resident #23.
Incomplete and non-person-centered care plans for pain management, wounds, and anemia for residents #53, #81, and #40.
Expired medication (albuterol inhaler) administered to resident #29.
Nystatin powder applied by CNA, which is outside CNA scope of practice, for resident #23.
Resident #81 with pressure ulcers had improperly applied heel protectors and lack of documented repositioning every two hours.
Resident #74 had unsecured medication (Breztri Aerosphere inhaler) left unattended in room.
Resident #23 had empty portable oxygen tank and oxygen tubing not changed as ordered.
Failure to administer prn pain medications as ordered and lack of non-pharmacological interventions for resident #53.
Less than eight consecutive hours of RN coverage on two days.
Expired medication administered to resident #75 (tramadol).
Unsecured medications left unattended on medication cart and in resident rooms; multi-dose vials not dated; expired medications not removed; medication labels missing expiration dates.
Resident #169 not provided meals according to preference for double portions; facility policy did not support double portions.
Failure to screen, educate, and document COVID-19 vaccination status for residents #63 and #74.
Report Facts
Medication error rate: 13.5
Late MDS assessments: 14
Late MDS assessments: 17
Late MDS assessments: 17
Late MDS assessments: 12
Late MDS assessments: 7
Late MDS assessments: 12
Late MDS assessments: 26
Late MDS assessments: 26
RN coverage hours: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Administered expired albuterol inhaler to Resident #29 |
| DON | Director of Nursing | Confirmed expired medication administration and lack of RN coverage |
| Kitchen Manager | Discussed grievance resolution and portion size policy | |
| Assistant Kitchen Manager | Explained difference between large and double portions | |
| Registered Dietician | Discussed diet orders and resident #169's portion size grievance | |
| CNA1 | Certified Nursing Assistant | Applied nystatin powder outside scope of practice |
| LPN2 | Licensed Practical Nurse | Confirmed expired medications and improper medication labeling |
| Regional MDS RN | Registered Nurse | Reported late and inaccurate MDS assessments |
| Social Worker | Involved in behavioral assessment for Resident #23 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding the misappropriation of $1600.00 cash missing from Resident #55's room.
Complaint Details
Resident #55 reported $1600.00 missing from the resident's room, suspected to be taken by a CNA, nurse, or housekeeper. The facility investigation did not include interviews with housekeeping staff, residents, or the resident's representative. The Administrator considered the investigation complete and the report unsubstantiated.
Findings
The facility failed to interview all persons involved in the investigation, specifically housekeeping staff, facility residents, and the resident's representative, despite suspicion that a CNA, nurse, or housekeeper may have taken the money. The investigation was considered complete by the Administrator, and the report of stolen money was unsubstantiated.
Deficiencies (1)
Facility failed to interview all persons involved in an investigation of misappropriation for 1 of 22 sampled residents (Resident #55).
Report Facts
Amount missing: 1600
Sampled residents: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager (BOM) | Provided information to Administrator and confirmed investigation was performed |
| Administrator | Administrator | Conducted interviews with staff, considered investigation complete |
| Licensed Social Worker | Licensed Social Worker (LSW) | Informed about missing money and involved in investigation |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, medication administration, assessment accuracy, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to provide meals according to resident preferences, incomplete and inaccurate care plans, medication errors including administration of expired medications and unsecured medications, inadequate RN coverage, failure to ensure timely and accurate assessments, improper pressure ulcer care, and failure to properly manage COVID-19 vaccination education and documentation.
Deficiencies (13)
Failed to resolve a resident grievance regarding physician orders and double portion food preferences for Resident #169.
Failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed or submitted timely for multiple months in 2023.
Failed to ensure accuracy of MDS assessment for Resident #23; behavioral section was completed incorrectly.
Failed to ensure care planned interventions for administering as needed pain medication were followed for Resident #53; care plans related to wounds and anemia were incomplete and not person centered for Residents #81 and #40 respectively.
Failed to ensure nystatin powder was applied by licensed staff for Resident #23.
Failed to ensure bed bound Resident #81 was repositioned every two hours and heel protectors were applied correctly, resulting in additional pressure ulcers.
Failed to ensure medications were not left unsecured in Resident #74's room, creating a potential accident hazard.
Failed to ensure Resident #23's portable oxygen tank was not empty and oxygen tubing was changed per physician's order.
Failed to ensure there were eight consecutive hours of Registered Nurse coverage for two days in December 2023.
Failed to ensure medication error rates were less than 5%, with 5 errors in 37 opportunities (13.51% error rate).
Failed to ensure drugs and biologicals were labeled properly and stored in locked compartments; included unsecured medications, missing open dates on multi-dose vials, expired medications not removed, and missing expiration dates on medication labels.
Failed to provide meals based on resident preferences for Resident #169, including failure to provide double portion diet orders as requested and approved.
Failed to provide education, screening, and documentation regarding COVID-19 vaccination for Residents #63 and #74.
Report Facts
Medication error rate: 13.51
Late MDS assessments: 14
Late MDS assessments: 17
Late MDS assessments: 17
Late MDS assessments: 42
Late MDS assessments: 12
Late MDS assessments: 10
Late MDS assessments: 7
Late MDS assessments: 35
Late MDS assessments: 12
Late MDS assessments: 26
Late MDS assessments: 19
Late MDS assessments: 26
Late MDS assessments: 19
RN coverage hours: 6.5
RN coverage hours: 6.08
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Manager | Named in grievance follow-up and food portion discussions for Resident #169 | |
| Assistant Kitchen Manager | Explained difference between large and double portions and portion size grid | |
| Registered Dietician | Spoke with Resident #169 about portion sizes and facility policy | |
| Regional Minimum Data Set (MDS) Registered Nurse | RN | Confirmed late completion of MDS assessments |
| MDS Coordinator | Verbalized MDS assessment completion process and accuracy issues | |
| Licensed Practical Nurse | LPN | Verbalized pain management process for Resident #53 |
| Director of Nursing | DON | Provided multiple clarifications on pain management, medication administration, RN coverage, and care planning |
| Certified Nursing Assistant | CNA | Demonstrated heel protector application and discussed repositioning |
| Wound Care Nurse | LPN | Documented wound evaluations and confirmed pressure ulcer care issues |
| Registered Nurse | RN | Confirmed unsecured medication and medication administration errors |
| VP of Clinical Services | Confirmed lack of COVID-19 vaccine education and documentation |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 3
Date: Dec 13, 2023
Visit Reason
The inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in several areas including incomplete tuberculosis (TB) testing for employees, failure to ensure timely dementia training, and lack of cultural competency training for certain employees. Corrective actions and monitoring plans were outlined for each deficiency.
Deficiencies (3)
Failure to complete tuberculosis testing for 6 of 20 sampled employees, including missing chest x-rays after positive PPD skin tests and incomplete two-step PPD testing prior to working with residents.
Failure to ensure eight hours of initial dementia training was completed within the first 30 days of employment for 2 of 20 sampled employees.
Failure to provide state-approved cultural competency training within 30 days of hire to 7 of 20 employees, risking potential discrimination and adverse psychosocial effects.
Report Facts
Census: 110
Sample size: 20
Deficiencies cited: 3
Inspection Report
Life Safety
Census: 81
Capacity: 120
Deficiencies: 5
Date: Dec 13, 2023
Visit Reason
The inspection was conducted as a Medicare Life Safety Code (LSC) recertification survey and an Emergency Preparedness survey at Wingfield Skilled Nursing and Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness program. Several deficiencies were identified related to Life Safety Code including unsealed smoke barrier penetrations, inaccurate circuit breaker labeling, combustible decorations on resident doors exceeding limits, improper use of extension cords and power strips, and improper storage of oxygen cylinders with combustible materials and mixing of empty and full cylinders.
Deficiencies (5)
Failed to ensure smoke barrier construction was properly sealed at points of penetration including holes in ceilings and doors.
Failed to ensure circuit breakers were accurately labeled; breakers marked as 'spare' were in 'on' position.
Combustible decorations on a resident room door covered approximately 72% of the corridor-facing side, exceeding allowed limits.
Improper use of extension cords, plug multipliers, and residential power taps in resident rooms.
Failed to properly segregate empty oxygen cylinders from full cylinders and failed to maintain required minimum 5 feet clearance between oxygen cylinders and combustible materials.
Report Facts
Resident census: 81
Total licensed capacity: 120
Percentage of door covered by combustible decorations: 72
Distance combustible materials stored from oxygen cylinders: 28
Number of oxygen cylinders in storage rack: 21
Date of compliance: Jan 9, 2024
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 4
Date: Nov 15, 2023
Visit Reason
The inspection was conducted as a result of Facility Reported Incidents (FRIs) and complaint investigations from 10/09/23 to 11/15/23, including allegations of medication errors, resident abuse, neglect, and elopement.
Complaint Details
The complaint investigations included allegations of a resident not given prescribed medication resulting in death (substantiated), theft of resident property (not substantiated), unwitnessed falls (not substantiated), verbal abuse by employee (not substantiated), racial slur by resident (not substantiated), CNA borrowing money from resident and not repaying (substantiated), resident elopements (substantiated), and resident-to-resident abuse (substantiated).
Findings
The facility was found deficient in preventing neglect resulting in a resident's death due to missed medication, failure to prevent resident-to-resident abuse in multiple cases, misappropriation of resident funds by a CNA, and failure to prevent elopements of residents. Several allegations were substantiated while others were not due to lack of evidence.
Deficiencies (4)
Failure to prevent neglect when medication was not administered per physician's order resulting in death of Resident #1.
Failure to prevent resident-to-resident abuse for multiple residents including hitting and throwing water.
Misappropriation of resident funds by a CNA borrowing money and failing to repay Resident #7.
Failure to provide adequate supervision resulting in elopement of residents #8 and #9.
Report Facts
Census: 107
Sample size: 20
Number of CPTs: 3
Number of FRIs: 15
Medication administrations missed: 9
Money borrowed: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Explained medication follow-up procedures and confirmed Brillinta was not stocked | |
| Director of Nursing (DON) | Provided statements on medication administration expectations, resident elopements, and abuse investigations | |
| Administrator | Confirmed expectations for medication follow-up and resident abuse investigations | |
| Pharmacy Manager | Explained medication order and fill process | |
| Certified Nursing Assistant (CNA) | Involved in misappropriation of resident funds and abuse allegations |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 15, 2023
Visit Reason
The inspection was conducted due to complaints and incidents involving resident abuse, neglect, misappropriation of property, elopement, and medication errors at Wingfield Skilled Nursing and Rehabilitation Center.
Complaint Details
The complaint investigation included substantiated allegations of neglect resulting in death due to medication errors (Resident #1), resident-to-resident abuse involving multiple residents (#9, #10, #11, #12, #13, #14), misappropriation of resident funds by a CNA (Resident #7), and failure to prevent elopements (Residents #8 and #9).
Findings
The facility failed to prevent resident-to-resident abuse for multiple residents, failed to administer prescribed medication resulting in a resident's death, failed to prevent misappropriation of resident funds by a staff member, and failed to provide adequate supervision to prevent resident elopements.
Deficiencies (4)
Failed to protect residents from abuse including resident-to-resident altercations resulting in injuries.
Failed to administer prescribed medication (Brillinta) resulting in death of Resident #1.
Failed to protect a resident from misappropriation of funds by a Certified Nursing Assistant.
Failed to provide adequate supervision to prevent elopement of residents.
Report Facts
Residents sampled for medication review: 31
Residents with documented resident-to-resident altercations: 8
Medication administrations missed: 9
Amount borrowed by CNA: 100
Additional unauthorized charge: 15.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unnamed Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Explained medication follow-up procedures and confirmed Brillinta was not stocked in automated medication dispensary. |
| Unnamed Director of Nursing | Director of Nursing (DON) | Confirmed failure to administer medication, described expectations for medication follow-up, and confirmed neglect in Resident #1 case; also confirmed elopement incidents. |
| Unnamed Administrator | Administrator | Explained expectations for nursing follow-up on missing medications and confirmed neglect in Resident #1 case. |
| Unnamed Pharmacy Manager | Pharmacy Manager | Explained medication order process and confirmed delay in filling Brillinta medication for Resident #1. |
| Unnamed Administrator | Administrator | Confirmed CNA misappropriation of Resident #7's funds and described disciplinary action. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: May 22, 2023
Visit Reason
The inspection was conducted as a result of a Facility Reported Incident (FRI) investigation triggered by allegations including resident-to-resident verbal abuse, sexual abuse by a Certified Nurses Assistant, and a resident fall causing a fracture.
Complaint Details
Three Facility Reported Incidents (FRIs) were investigated: FRI #NV00068136 (resident-to-resident verbal abuse), FRI #NV00068278 (alleged sexual abuse by a Certified Nurses Assistant), and FRI #NV00068556 (resident fall causing fracture). None of the allegations were substantiated due to lack of evidence.
Findings
The investigations into all three allegations could not be substantiated due to lack of evidence. Observations, interviews with staff and residents, document reviews, and policy reviews were conducted. No regulatory deficiencies were identified and no further action was necessary.
Report Facts
Sample size: 5
Number of FRIs investigated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed during investigations |
| Administrator | Administrator | Interviewed during investigations |
| Licensed Social Worker | Licensed Social Worker (LSW) | Interviewed during investigations |
| Licensed Practical Nurses | Licensed Practical Nurses (LPN) | Two LPNs interviewed during investigations |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 4
Date: Nov 18, 2022
Visit Reason
This inspection was conducted as a State Licensure Survey in conjunction with a Federal Recertification survey to assess compliance with Nevada Administrative Code Chapter 449 for Skilled Nursing Facilities.
Findings
The facility was found deficient in several areas including incomplete tuberculosis (TB) testing and fingerprinting for employees, failure to ensure timely dementia training, failure to ensure cultural competency training completion, and inadequate housekeeping related to exhaust fan cleanliness.
Deficiencies (4)
Failure to complete Tuberculosis (TB) testing and timely submission of fingerprints for clearance for several employees.
Failure to ensure eight hours of initial dementia training was completed within the first 30 days of employment and annually for some employees.
Failure to maintain exhaust openings free from accumulation of dirt in bathrooms.
Failure to ensure cultural competency training was completed for some employees.
Report Facts
Census: 85
Sample size: 20
Deficiency scope: 1
Deficiency severity: 2
Deficiency scope: 1
Deficiency severity: 2
Deficiency scope: 1
Deficiency severity: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Director of Nursing | Named in tuberculosis testing deficiency |
| Employee #4 | Registered Dietician | Named in tuberculosis testing and fingerprinting deficiency |
| Employee #6 | Nutrition Services Supervisor | Named in dementia training deficiency |
| Employee #10 | Occupational Therapy Aide | Named in fingerprinting deficiency |
| Employee #12 | Infection Preventionist/Assistant Director of Nursing | Named in tuberculosis testing deficiency |
| Employee #14 | Licensed Practical Nurse | Named in tuberculosis testing deficiency |
| Employee #15 | Licensed Practical Nurse | Named in cultural competency training deficiency |
| Employee #16 | Certified Nursing Assistant | Named in cultural competency training deficiency |
| Employee #17 | Certified Nursing Assistant / Cook | Named in tuberculosis testing and fingerprinting deficiency |
| Employee #18 | Cook | Named in dementia training deficiency |
| Employee #19 | Dietary Aide | Named in fingerprinting deficiency and noted no longer employed |
Inspection Report
Routine
Census: 85
Deficiencies: 20
Date: Nov 18, 2022
Visit Reason
The inspection was conducted as a routine survey of Wingfield Skilled Nursing and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, care planning, medication administration, infection control, and other health and safety standards.
Findings
The facility was found deficient in multiple areas including failure to provide residents with access codes to exit and re-enter the facility courtyard, lack of informed consent for use of a WanderGuard alert bracelet, incomplete care plans for residents' needs including pain management and tube feeding, failure to provide showers as scheduled, medication errors with a high error rate, improper infection control practices including improper PPE use and inadequate cleaning, failure to ensure timely influenza and COVID-19 vaccinations, and failure to maintain accurate staff vaccination exemption documentation.
Deficiencies (20)
Failed to ensure residents were provided notification of how to exit the facility and access the courtyard autonomously.
Failed to obtain informed consent prior to use of a WanderGuard alert bracelet for Resident #30.
Failed to provide a functional call light device for Resident #42 with quadriplegia.
Failed to ensure an Advanced Directive Acknowledgement form was completed for Resident #336.
Failed to provide a safe environment by not providing a means to immediately re-enter the facility from the courtyard and lack of monitoring residents outside.
Failed to develop a baseline care plan to meet immediate needs for Resident #335 on comfort/palliative care.
Failed to develop and implement complete care plans including interventions for activities of daily living and pain management for Residents #50 and #64.
Failed to provide scheduled showers or bed baths to dependent residents #33 and #80.
Failed to coordinate care with hospice provider for Resident #42 and maintain hospice communication forms.
Failed to ensure physician's order for oxygen was followed for Resident #33 (oxygen set at 3 LPM instead of 2 LPM).
Failed to post nurse staffing information daily in a prominent location.
Failed to ensure medication was administered with an error rate less than 5 percent; medication error rate was 55.17%.
Failed to remove expired medication (acetaminophen 160 mg) from medication cart.
Failed to ensure food safety including proper labeling, storage, hand hygiene, hairnet use, ice machine cleanliness, and covered food and beverages during delivery.
Failed to document completion of physician orders for indwelling catheter care for Resident #30.
Failed to ensure staff properly wore PPE in resident accessible areas and in the laundry room, and failed to ensure required cleaning in laundry room was completed.
Failed to ensure the designated Infection Preventionist completed required training and the facility had a qualified IP from 04/23/22 to 10/25/22.
Failed to ensure residents eligible for influenza and pneumococcal vaccines were offered vaccines and documented accordingly.
Failed to ensure residents requesting COVID-19 vaccine were vaccinated and documented accordingly.
Failed to ensure medical and non-medical COVID-19 vaccine exemptions for staff were accurately completed and approved.
Report Facts
Residents affected: 7
Medication error opportunities: 29
Medication errors: 16
Medication error rate: 55.17
Facility census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed lack of informed consent for WanderGuard and care plan deficiencies | |
| Assistant Director of Nursing | Identified as lead Infection Preventionist and confirmed vaccine clinic cancellation | |
| Licensed Practical Nurse | Administered medication with error and confirmed medication order discrepancies | |
| Certified Nursing Assistant | Mentioned in relation to call light and shower assistance deficiencies | |
| Kitchen Manager | Confirmed food safety and hygiene deficiencies | |
| Infection Preventionist | Confirmed PPE and vaccination documentation deficiencies |
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