Inspection Reports for Wingfield Skilled Nursing And Rehabilitation Center

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.

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.

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.

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.

An offsite revisit was conducted on 01/18/24 for all previous deficiencies cited on 12/12/23.

All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.