Inspection Reports for Winfield Senior Living Community
1320 WHEAT ROAD, KS, 67156-4704
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 9, 2025, found the facility in compliance with all regulations and no deficiencies. Prior inspections showed a pattern of deficiencies primarily related to resident care planning, medication management, infection control, and safety measures such as fall prevention and supervision. Complaint investigations substantiated issues including inadequate supervision leading to resident falls and elopement risks, as well as delayed or incomplete care plan revisions and medication administration errors. Enforcement actions included denial of payment for new Medicare and Medicaid admissions at times, and an immediate jeopardy finding in 2021 related to failure to initiate CPR, which was later resolved after corrective measures. The facility has demonstrated improvement over time, with recent inspections showing correction of previously cited deficiencies and no new noncompliance noted.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
25.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
320% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
72 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
A revisit survey was conducted on 04/09/25 for all previous deficiencies cited on 02/06/25 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 03/15/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Mar 15, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies, outlining corrective actions, systematic changes, and monitoring plans to achieve substantial compliance with federal Medicare and Medicaid requirements.
Findings
The Plan of Correction details multiple corrective actions addressing deficiencies related to resident transfers, care plan updates, hot liquid safety, medication administration, fall interventions, nutritional status, dialysis care, memory care activities, medication cart security, facility assessment, infection control, and immunizations. Each corrective action includes education, audits, and monitoring to ensure compliance.
Deficiencies (18)
Facility provided written notification of the reason and location for the facility-initiated transfer to resident at time of transfer.
Facility updated care plans to reflect current transfer status, fluid restrictions, dialysis completion days, and documentation.
Facility completed hot liquid assessment and updated care plans to prevent burns from hot liquids.
Facility updated care plan with current home exercise program for upper extremity range of motion.
Facility updated care plan with current fall intervention.
Facility reviewed weight and nutritional status, updated care plan with expectations for weight loss.
Facility updated care plan with current dialysis days and fluid restrictions.
Facility initiated activity calendar and charting system for memory care residents.
Facility ensured certified medication aides and licensed staff count narcotic boxes at shift changes.
Facility educated licensed nursing employees on dialysis physician orders and documentation.
Facility educated staff on dementia policy and person-centered activities for memory care residents.
Facility educated nursing staff on proper use of narcotic hand count sheets and medication counting.
Facility reviewed medication orders and educated staff on parameters for safe medication administration.
Facility reviewed psychotropic medication indications and ensured physician rationale and gradual dose reduction attempts.
Facility educated charge nurses on security of medication cart policy.
Facility updated facility assessment to reflect resources necessary for resident care during operations and emergencies.
Staff educated on proper storage and disposal of face masks, nasal cannulas, and Legionella water management plan.
Facility reviewed and documented immunizations and preferences for residents.
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Dates of corrective actions: Feb 19, 2025
Dates of corrective actions: Feb 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
| Deb Harper | Added and modified the Plan of Correction |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 16
Date: Feb 6, 2025
Visit Reason
The inspection was an annual health resurvey of Winfield Senior Living Community to assess compliance with federal regulations related to resident care, medication management, infection control, and facility operations.
Findings
The facility was cited for multiple deficiencies including failure to provide written transfer notifications, incomplete care plan revisions, inadequate quality of care evaluations, failure to prevent decline in range of motion, unsafe medication storage and administration, lack of appropriate psychotropic medication management, incomplete facility-wide assessment, infection control lapses, and failure to ensure pneumococcal immunizations were offered or documented.
Deficiencies (16)
Failed to provide written notification of the reason and location for a facility-initiated transfer for Resident 44.
Failed to revise Resident 12's care plan to reflect current transfer requirements and failed to revise Resident 23's hospice care planned interventions.
Failed to evaluate Resident 27's risks and abilities related to handling hot liquids, placing the resident at risk for preventable accidents and injuries.
Failed to ensure Resident 38 was provided services and treatment to prevent worsening of contractures in his left hand.
Failed to ensure Resident 16's safety related to following care-planned fall interventions, including use of Dycem mat and gait belt.
Failed to identify and implement nutritional interventions related to Resident 26's continued weight loss.
Failed to ensure Resident 23 had a physician order for hemodialysis that included an indication and failed to monitor fluid restriction.
Failed to provide necessary person-centered activities and interventions to address Resident 13's dementia diagnosis including close supervision to prevent wandering and falls.
Failed to ensure controlled substances were accounted for and reconciled between shifts.
Consulting pharmacist failed to identify and make recommendations related to Resident 12's Midodrine medication.
Failed to ensure safe medication administration for Resident 12's Midodrine medication with lack of blood pressure monitoring parameters and administration despite elevated blood pressure readings.
Failed to ensure appropriate indication or documented physician rationale for Resident 26's antipsychotic medication and failed to ensure physician rationale for continued use of as-needed psychotropic medications beyond 14 days.
Failed to ensure safe medication storage of one medication cart which was found unsecured in the hallway.
Failed to conduct a thorough facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies, including staffing levels and contingency plans.
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 water management program.
Failed to offer or obtain informed declinations or physician-documented contraindications for Pneumococcal Conjugate Vaccine (PCV20) for Residents 1, 12, 27, and 28.
Report Facts
Weight loss: 26.4
Medication administration blood pressure: 177
Medication administration blood pressure: 158
Medication administration blood pressure: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding facility practices, policies, and deficiencies including transfer notification, care plan revisions, medication administration, facility assessment, infection control, and dialysis monitoring. |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements regarding care plan accuracy, fluid intake documentation, fall risk, and infection control practices. |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding care plan accuracy, medication administration parameters, dialysis monitoring, and infection control. |
| Certified Medication Aide R | Certified Medication Aide | Provided statements regarding staffing and activity provision on memory care unit. |
| Activity Z | Activity Staff | Provided statements regarding activity programming and staffing on memory care unit. |
| Administrative Nurse E | Administrative Nurse / Infection Preventionist | Provided statements regarding medication cart security, immunization tracking, and infection prevention. |
| Licensed Nurse I | Licensed Nurse | Provided statements regarding medication cart security. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
An offsite revisit survey was conducted on 01/15/25 for all previous deficiencies cited on 01/07/25 to verify correction of cited deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 01/08/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
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 conducted as a licensure resurvey for the facility.
Findings
The facility failed to ensure that a functional capacity screening was performed for Resident 3 at least once every 365 days, as required by regulation.
Deficiencies (1)
Failure to perform a functional capacity screening for Resident 3 at least once every 365 days.
Report Facts
Census: 17
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named as responsible for failure to ensure screening was performed | |
| Licensed Nurse (LN) A | Confirmed the functional capacity screening for Resident 3 was greater than 365 days old |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
An offsite revisit survey was conducted on 10/21/24 for all previous deficiencies cited on 08/26/24 to verify correction of cited deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 09/17/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
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 report dated 8.26.24.
Findings
The plan outlines corrective actions to ensure timely activation and revision of care plans and provision of Activities of Daily Living (ADL) care according to policies and orders, including staff education and monitoring schedules.
Deficiencies (2)
Care Plan Timing and Revision
Activities Daily Living (ADLs) Maintenance Abilities
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
| Teresa Edwards | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Aug 26, 2024
Visit Reason
A complaint survey was conducted regarding allegations in KS00189594. The investigation was triggered by concerns about the facility's failure to revise care plans and provide necessary bathing services to a resident.
Complaint Details
The complaint investigation revealed noncompliance related to care plan timing and revision as well as activities of daily living, specifically bathing services. The facility did not notify Resident 1's family member when the resident refused bathing, contrary to facility policy.
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. Resident 1 refused baths, and staff did not notify the family member as required by facility policy.
Deficiencies (2)
Failed to revise Resident 1's care plan to reflect interventions related to personal hygiene.
Failed to provide Resident 1 with necessary bathing services to maintain good grooming and personal hygiene.
Report Facts
Census: 40
Days without bath: 24
BIMS score: 11
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide D | Certified Nurse Aide | Interviewed regarding bathing services and documentation practices |
| Licensed Nurse C | Licensed Nurse | Interviewed regarding bathing schedule and family notification |
| Administrative Nurse B | Administrative Nurse | Interviewed regarding family notification protocol when Resident 1 refused bath |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
An offsite revisit survey was conducted on 01/24/24 for all previous deficiencies cited on 01/11/24 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 01/24/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 19
Deficiencies: 3
Date: Jan 11, 2024
Visit Reason
The inspection was a licensure resurvey conducted on 01/10/24 and 01/11/24 to assess compliance with state regulations for the facility.
Findings
The facility was found deficient in conducting functional capacity screenings at least annually, reviewing and revising negotiated service agreements annually, and ensuring compliance with tuberculosis testing guidelines for new hires and residents.
Deficiencies (3)
Failure to conduct a functional capacity screening for Resident 2 at least once every 365 days.
Failure to review and revise the Negotiated Service Agreement for Resident 2 at least once every 365 days.
Failure to ensure compliance with tuberculosis guidelines, including lack of timely TB testing documentation for Resident 1 and newly hired Certified Medication Aide C.
Report Facts
Census: 19
Residents sampled: 3
Newly hired staff sampled: 1
Employment start date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Named in tuberculosis testing deficiency |
| LN A | Licensed Nurse | Interviewed regarding deficiencies and confirmed lack of documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 10, 2024
Visit Reason
The 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
Re-Inspection
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
A revisit survey was conducted on 06/06/23-06/07/23 for 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 on 06/06/23-06/07/23 for 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
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 was found deficient in multiple areas including failure to prevent falls due to inadequate use of gait belts and walkers, inadequate hydration for a dependent resident, failure to ensure pain medication was swallowed, unsanitary food storage and preparation practices, and failure to provide documentation of influenza and pneumococcal immunizations or declinations for several residents.
Deficiencies (5)
Failure to provide safe ambulation with planned interventions to prevent accidents, resulting in a resident fall and injury.
Failure to provide adequate hydration for a dependent resident, observed with dry lips, deep tongue grooves, and insufficient fluid intake.
Failure to ensure appropriate pain control by not ensuring the resident swallowed the pain medication.
Failure to provide sanitary food preparation and storage, including expired or improperly dated foods, risking food borne illness.
Failure to provide proof of vaccination or declination for influenza and pneumococcal vaccines for three residents reviewed.
Report Facts
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 during ambulation and provided statements about gait belt use and hydration |
| Certified Nurse Aide M | Certified Nurse Aide | Stated staff should always use gait belts and offer water during cares |
| Licensed Nurse G | Licensed Nurse | Stated staff should use gait belts and walker for resident ambulation |
| Licensed Nurse H | Licensed Nurse | Stated gait belts should be used and observed resident with pain medication not swallowed |
| Administrative Nurse D | Administrative Nurse | Stated expectations for gait belt use, hydration, medication administration, and immunization documentation |
| Certified Medication Aide R | Certified Medication Aide | Administered crushed pain medication and noted resident pocketed pills |
| Dietary Staff CC | Dietary Staff | Provided information about food storage and preparation practices |
| Dietary Staff BB | Dietary Staff | Provided information about food storage guidelines and date marking |
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 identified during the Annual Survey completed on April 19, 2023.
Findings
The Plan of Correction addresses multiple deficiencies including fall prevention, nutrition and hydration, pain management, food procurement and preparation, immunizations, and maintenance of soiled work rooms. Corrective actions include staff education, audits, and monitoring plans to ensure compliance and resident safety.
Deficiencies (6)
Free of accidents hazards/supervision/devices
Nutrition/Hydration Status Maintenance
Pain Management
Food Procurement, store/prepare/serve sanitary
Influenza and Pneumococcal Immunizations
Soiled Work Room
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Renewal
Census: 17
Deficiencies: 5
Date: Dec 20, 2022
Visit Reason
The inspection was a licensure resurvey with an attached complaint number 171380 conducted on 12/19/2022 and 12/20/2022 at Winfield Senior Living Community.
Complaint Details
The inspection included an attached complaint number 171380.
Findings
The facility was found deficient in multiple areas including failure to revise negotiated service agreements based on residents' functional capacity screens, lack of documentation of licensed nurse responsible for health care service plans, inadequate documentation of incidents and actions taken for residents, failure to conduct quarterly emergency preparedness plan reviews with staff and residents, noncompliance with infection control policies including tuberculosis screening, and failure to document actions taken for residents' changes in condition.
Deficiencies (5)
Failure to revise resident's Negotiated Service Agreement based on Functional Capacity Screen and provide description of services and payor source when resident experienced change of condition.
Negotiated Service Agreement lacked the name of the licensed nurse responsible for implementation and supervision of the Health Care Service Plan for residents 1, 2, and 3.
Resident records lacked documentation of all incidents, symptoms, actions taken, and results of actions for residents 1, 2, and 3.
Failure to review the facility's emergency management plan quarterly with staff and residents.
Failure to ensure compliance with tuberculosis screening guidelines for adult care homes, specifically lack of documentation of required two-step TB test within seven days of residency for resident 2.
Report Facts
Census: 17
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Named in relation to multiple findings including failure to revise NSAs, failure to ensure documentation, and failure to conduct emergency preparedness reviews. |
| Licensed Nurse B | Licensed Nurse | Interviewed regarding deficiencies related to NSAs, health care service plans, resident documentation, and tuberculosis screening. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 19, 2022
Visit Reason
The document is a plan of correction addressing findings from a licensure resurvey with an attached complaint number 171380, conducted on 12/19/2022 and 12/20/2022.
Complaint Details
The inspection was related to complaint number 171380 attached to the licensure resurvey.
Findings
The plan of correction corresponds to citations found during the licensure resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
A revisit survey was conducted on 12/01/22 for all previous deficiencies cited on 10/03/22.
Findings
All deficiencies have been corrected as of the compliance date of 10/03/22, and no new noncompliance was found. 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 document is a Plan of Correction responding to 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 reporting violations at Winfield Senior Living.
Findings
The facility was found in compliance with COVID-19 practices but had multiple deficiencies including neglect of a cognitively impaired resident left unsupervised outside in high temperatures causing altered mental status and hospitalization, failure to report an injury accident to the state agency within required timeframes, and failure to provide a safe environment free of accident hazards related to removal of a bathroom door in the memory care unit. These deficiencies placed residents at immediate jeopardy or risk of harm.
Deficiencies (3)
Neglect of cognitively impaired resident left unsupervised outside for 1 hour 50 minutes in 97°F temperatures resulting in altered mental status and hospitalization.
Failure to report an injury accident/fall for a resident to the state agency within five days as required.
Failure to provide an environment free of accident hazards due to removal and unsecured placement of bathroom door in memory care unit, resulting in resident injury.
Report Facts
Census: 43
Residents in memory care unit: 10
Residents in sample reviewed for accidents: 3
Residents in sample reviewed for lack of supervision: 3
Duration resident left unsupervised outside: 110
Resident body temperature: 102.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
| Evelyn Lacey | Added Plan of Correction on 10/10/2022 | |
| Lori Mouak | Modified Plan of Correction on 01/18/2023 | |
| Certified Nurse Aide M | Certified Nurse Aide | Observed resident injury and notified Licensed Nurse |
| Licensed Nurse G | Licensed Nurse | Called 911 for emergency medical services for injured resident |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Sep 27, 2022
Visit Reason
The inspection was a partial extended survey with complaint investigations #174911 and #175055, including a Targeted Infection Control Survey/COVID-19 Focused Survey.
Complaint Details
The complaint investigations involved allegations of neglect and failure to report injuries. The facility was found to have neglected a cognitively impaired resident by leaving her outside unsupervised in extreme heat, and failed to report a resident's injury fall to the state agency within required timeframes.
Findings
The facility was found in compliance with COVID-19 practices but failed to ensure safety and supervision of cognitively impaired residents, resulting in immediate jeopardy for one resident left outside in extreme heat and another resident who suffered a fall due to an unsecured hazardous environment. The facility also failed to report an injury fall to the state agency within required timeframes.
Deficiencies (3)
Failure to ensure safety of cognitively impaired resident left outside unsupervised for 1 hour and 50 minutes in 97°F heat, resulting in altered mental status and hospitalization.
Failure to report an injury fall of a resident to the state agency within five days as required.
Failure to provide an environment free of accident hazards by leaving a bathroom door removed and unsecured in an unoccupied room, resulting in a resident fall with subdural hematoma and skull fracture.
Report Facts
Residents present: 43
Resident outside unsupervised duration: 110
Resident temperature: 102.5
Resident fall date: Sep 22, 2022
Resident fall report delay: 5
Date bathroom door removed: Aug 12, 2022
Date unsecured door removed: Sep 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Noted resident R1 outside in heat, assisted resident inside, observed altered mental status and high temperature |
| Licensed Nurse D | Licensed Nurse | Assisted Licensed Nurse C with resident R1 after being found outside |
| Certified Nurse Aide F | Certified Nurse Aide | Let resident R1 outside and later assisted resident outside again, unaware if fluids were provided |
| Licensed Nurse G | Licensed Nurse | Responded to resident R1 fall, called physician and EMS, documented injury and hospital communication |
| Certified Nurse Aide M | Certified Nurse Aide | Discovered resident R1 lying on floor after fall in unsecured room, notified Licensed Nurse G |
| Maintenance Staff U | Maintenance Staff | Removed bathroom door and placed it in unsecured room, failed to secure door |
| Administrative Staff A | Administrative Staff | Received IJ notification, reported failure to report fall to state agency |
| Administrative Staff B | Administrative Staff | Stated expectation for supervision of cognitively impaired residents outside and lack of facility policy on monitoring residents outside |
| Administrative Nurse D | Administrative Nurse | Reported maintenance staff should not have left door unsecured |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 29, 2021
Visit Reason
This document is a Plan of Correction submitted by Winfield Senior Living in response to deficiencies cited during a prior inspection related to cardiopulmonary resuscitation (CPR) training and policy compliance.
Findings
The plan outlines corrective actions including a full house audit for code status, training of all department heads and staff on CPR requirements, monitoring through random CPR audits, and ongoing review by the QAPI Committee to ensure compliance and sustainment of the Emergency Procedure – Cardiopulmonary Resuscitation Policy.
Deficiencies (1)
Failure to ensure all staff were trained on CPR policy and procedures as required.
Report Facts
Dates for corrective actions: Nov 30, 2021
Dates for audits: 7
Audit frequency: 4
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Evelyn Lacey | Added the Plan of Correction | |
| Lori Mouak | Modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Nov 29, 2021
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services (KDADS) on behalf of CMS due to complaint investigation #167362 to determine compliance with 42 CFR 483 subpart B.
Complaint Details
Complaint investigation #167362 found the facility not in substantial compliance with 42 CFR 483 subpart B due to failure to initiate CPR on a resident with 'Full Code' status. Immediate jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to initiate cardiopulmonary resuscitation (CPR) on one 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 plan including staff training and audits.
Deficiencies (1)
Failure to initiate CPR on a resident with 'Full Code' status found unresponsive and without a pulse.
Report Facts
Census: 40
Sample size: 13
Date of incident: Nov 23, 2021
Date of survey: Nov 29, 2021
Date immediate jeopardy removed: Dec 1, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Did not initiate CPR on the resident found unresponsive. |
| Certified Nurse Aide M | Certified Nurse Aide | Not CPR certified; found resident unresponsive and alerted Certified Medication Aide. |
| Certified Medication Aide R | Certified Medication Aide | CPR certified; alerted Licensed Nurse G but was not instructed to initiate CPR. |
| Administrative Nurse D | Administrative Nurse | Stated expectation that Licensed Nurse G should have started CPR. |
| Administrative Staff A | Administrative Staff | Informed of immediate jeopardy and notified that immediate action was needed. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The document is a Plan of Correction submitted in response to a Deficiency Free Survey conducted on 11/18/2021.
Findings
The facility was found to be deficiency free during the survey conducted on 11/18/2021.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The health survey was conducted as a regulatory inspection of the long term care facility to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 7
Date: Mar 29, 2021
Visit Reason
This report documents a revisit conducted to verify that previously reported deficiencies have been corrected and to confirm the dates when corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date, March 29, 2021.
Deficiencies (7)
Deficiency related to regulation 26-41-201 (c)
Deficiency related to regulation 26-41-204 (d)
Deficiency related to regulation 26-41-205 (a) (1)
Deficiency related to regulation 26-41-205 (b)
Deficiency related to regulation 26-41-205 (h)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Report Facts
Deficiencies corrected: 7
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, lack of identification of responsible parties for medication administration, improper medication storage practices with undated insulin pens, failure to provide quarterly emergency preparedness training, and non-compliance with tuberculosis screening requirements for new employees.
Deficiencies (7)
Failure to ensure functional capacity screening for resident #121 was conducted at least once every 365 days.
Negotiated service agreements for residents #121, #211, and #312 lacked identification of the licensed nurse responsible for implementation and supervision of the health care service plan.
Failure to ensure licensed nurse performed an annual assessment for self-administration of medications for resident #121.
Negotiated service agreement for resident #121 lacked identification of who was responsible for administration and management of selected medications.
Licensed nurse administered medication beyond the manufacturer's recommended expiration date regarding insulin pens for residents #416, 518, 621, 741, and 856; pens lacked date of opening.
Failure to provide quarterly emergency and disaster preparedness training to staff and residents.
Failure to ensure compliance with tuberculosis guidelines; new employee lacked evidence of 2-step TB test within 7 days of hire.
Report Facts
Census: 15
Residents in sample: 3
Residents with insulin pens undated: 5
New employee missing TB test: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator B | Administrator | Interviewed confirming multiple deficiencies including lack of functional capacity screening, incomplete negotiated service agreements, lack of emergency preparedness training, and missing TB test documentation. |
| Certified Medication Aide C | Certified Medication Aide | Interviewed and observed medication storage practices; confirmed insulin pens lacked opening dates. |
| Licensed Nurse A | Licensed Nurse | Newly hired employee lacking evidence of 2-step TB test; confirmed missing medication self-administration assessment for resident #121. |
| Licensed Nurse B | Licensed Nurse | Confirmed insulin pens lacked dates of opening. |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/13/2020.
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: 1
Date: Jun 16, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a COVID-19 survey conducted at the facility.
Findings
The COVID-19 survey conducted on 06/16/2020 was deficiency free, indicating no deficiencies were found during the inspection.
Deficiencies (1)
DEFICIENCY FREE COVID 19 SURVEY.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 13, 2020
Visit Reason
An offsite revisit was conducted on 04/13/2020 for all previous deficiencies cited on 02/04/2020.
Findings
All deficiencies have been corrected as of the compliance date of 03/18/2020, 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 identified deficiencies related to fall interventions, nebulizer kit disinfection and storage, insulin administration, and blood pressure and blood sugar monitoring.
Findings
The plan addresses multiple deficiencies including revision of care plans for fall interventions, re-education of nursing staff on fall policy and incident reporting, proper disinfection and storage of nebulizer kits, and monitoring and notification procedures for insulin and blood pressure management.
Deficiencies (5)
Care plans (R42, R41, R17) will be revised to reflect current fall interventions
Resident R32’s nebulizer kit will be replaced, disinfected, and stored appropriately
Resident R41 will receive insulin per order and notify physician if blood sugars are outside parameters
Resident R13 will notify physician of blood pressure readings out of parameters and have adequate monitoring; Resident R41 will notify when insulin was held
Residents R13 and R19’s blood pressures and blood sugars out of parameters will be notified to physician
Report Facts
Audit frequency: 5
Audit frequency: 1
Audit frequency: 5
Audit frequency: 3
Audit frequency: 5
Audit frequency: 3
Audit frequency: 5
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 6
Date: Feb 4, 2020
Visit Reason
Health Resurvey and Complaint Investigation #146866 conducted to assess compliance with care plan timing, revision, accident hazards, respiratory care, and medication administration.
Complaint Details
Complaint Investigation #146866 included review of care plan revisions, fall investigations, medication administration, and respiratory care.
Findings
The facility failed to timely review and revise care plans following resident falls, implement interventions to prevent further falls, properly clean and store nebulizer equipment, and follow physician orders for insulin administration and blood pressure monitoring. Medication regimen reviews failed to identify irregularities, and staff held insulin without physician orders or notification.
Deficiencies (6)
Failure to timely review and revise care plans following falls for residents R42, R41, and R17, including lack of immediate interventions to prevent further falls.
Failure to implement interventions following falls to prevent further falls for residents R42, R41, and R17.
Failure to properly clean and store nebulizer administration kit for Resident R32, risking respiratory infections.
Failure to follow physician orders for Resident R41 by not administering insulin as ordered on 12 occasions and failing to notify physician when blood sugar was above 350.
Failure to identify medication monitoring irregularities for Resident R13, who received antihypertensive medications without adequate blood pressure monitoring and physician notification.
Failure to ensure medication regimen free from unnecessary drugs for Residents R13 and R19 due to inadequate monitoring of blood pressure and medication effects.
Report Facts
Resident census: 47
Residents sampled: 13
Insulin doses not administered: 12
Blood pressure diastolic readings: 6
Blood sugar range: 77
Blood sugar range: 385
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Reported fall protocol and interventions for Resident R42 |
| LN J | Licensed Nurse | Reported director of nursing investigated resident falls |
| LN K | Licensed Nurse | Reported care plan revision responsibilities and fall risk for Resident R42 |
| Administrative Nurse D | Administrative Nurse | Reported on fall investigations and medication administration issues |
| CNA N | Certified Nursing Assistant | Reported observations and interventions related to Resident R42 falls |
| CNA O | Certified Nursing Assistant | Reported observations and interventions related to Resident R42 falls |
| CMA R | Certified Medication Aide | Reported on Resident R41 supplement intake and insulin holding |
| LN I | Licensed Nurse | Reported nebulizer cleaning procedure |
| LN K | Licensed Nurse | Reported blood pressure monitoring and insulin administration issues for Residents R13 and R41 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 28, 2019
Visit Reason
An offsite revisit was conducted on 10/28/19 for all previous deficiencies cited on 08/28/19.
Findings
All deficiencies have been corrected as of the compliance date of 09/27/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Deficiency compliance date: 92719
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Aug 28, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#143528) regarding a fall incident involving Resident 1 at Winfield Senior Living Community.
Complaint Details
The complaint investigation #143528 found that the facility staff failed to ensure adequate supervision and gait belt usage during toileting, leading to a fall and injury of Resident 1.
Findings
The facility failed to provide adequate supervision and use of assistive devices to prevent a fall for one resident. A Certified Nurse Aide removed the gait belt and unlocked wheelchair brakes, resulting in the resident standing and falling, causing injuries including a nasal bone fracture and facial hematoma.
Deficiencies (1)
Failure to provide adequate supervision and assistive device to prevent a fall for Resident 1.
Report Facts
Census: 38
Fall Risk Score: 15
Admission Date: Jun 7, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in the finding for failing to provide adequate supervision and gait belt usage during toileting |
| LN C | Licensed Nurse | Assessed the resident after the fall and called EMS |
| Administrative Nurse B | Administrative Nurse | Verified facility staff were to utilize 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 cited during a prior inspection.
Findings
The plan addresses a deficiency related to improper gait-belt usage during resident transfers and toileting, with corrective actions including staff re-education, audits, and ongoing monitoring.
Deficiencies (1)
Improper gait-belt usage while transferring and toileting resident R1
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
An offsite revisit survey was conducted on 03/05/2019 for all previous deficiencies cited on 01/28/2019.
Findings
All deficiencies have been corrected as of the compliance date of 02/27/2019, 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 in a prior inspection, including allegations of exploitation/misappropriation of money and issues related to catheter care and kitchen sanitation.
Findings
The Plan of Correction addresses multiple deficiencies including exploitation/misappropriation of resident funds, catheter care practices, and sanitation and maintenance issues in the kitchen and storage areas. Corrective actions include staff education, audits, cleaning, repairs, and ongoing monitoring with reports to the QAPI Committee.
Deficiencies (5)
Allegation of exploitation/misappropriation of money for Resident #10
Investigation of missing money for Resident #10
Improper placement and handling of catheter drainage bag for Resident #33
Sanitation and maintenance deficiencies in dry storage room and kitchen areas
Sanitation and maintenance deficiencies including ceiling vents, floor, and electrical safety
Report Facts
Dates of corrective actions: Jan 28, 2019
Dates of corrective actions: Jan 31, 2019
Frequency of catheter observation audits: 5
Duration of catheter observation audits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tomisha Jordan | Executive Director | Submitted the Plan of Correction to KDADS |
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, focusing on allegations of abuse, neglect, exploitation, and compliance with regulatory requirements.
Complaint Details
The complaint investigation involved allegations of exploitation/misappropriation of money for resident #10. The facility delayed reporting the incident to the state agency and police by three days after the resident reported $40 missing. The investigation was ongoing at the time of the survey.
Findings
The facility failed to timely 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)
Failed to report an allegation of exploitation/misappropriation of money for resident #10 to the state agency as required.
Failed to thoroughly investigate timely the missing money allegation for resident #10.
Failed to ensure proper handling of the catheter drainage bag for resident #33 to prevent urinary tract infections.
Failed to maintain a clean and sanitary dietary department, including issues such as debris, grime, and grease build-up on multiple kitchen surfaces and equipment.
Failed to provide maintenance services for the kitchen to ensure a safe and sanitary environment, including issues with ceiling vents, floors, walls, and ceiling conditions.
Report Facts
Census: 38
Missing money amount: 40
Resident BIMS score: 12
Resident BIMS score: 15
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Social Worker | Interviewed regarding the missing money report and investigation for resident #10. |
| Staff C | Licensed Nursing Staff | Reported initial notification of missing money and catheter care observations. |
| Staff A | Administrative Staff | Contacted corporate regarding reportability of missing money and delayed reporting to state agency and police. |
| Staff F | Administrative Nursing Staff | Discussed catheter bag placement with resident #33 and provided education. |
| Staff B | Dietary Staff | Reported lack of system for maintaining a clean, sanitary kitchen and acknowledged environmental concerns. |
| Staff D | Direct Care Staff | Removed catheter drainage bag from improper placement and provided appropriate care. |
| Staff E | Direct Care Staff | Verified proper catheter bag placement. |
| Staff G | Direct Care Staff | Stated catheter drainage bag should have dignity cover and not be on floor or beside resident. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 28, 2019
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at a 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2019-02-27.
Deficiencies (1)
Most serious deficiency at a 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jul 3, 2018
Visit Reason
This report documents a revisit conducted to verify that previously identified deficiencies at Winfield Senior Living Community have been corrected.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 26-41-204 (e)
Deficiency related to regulation 26-41-205 (d) (4)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-207 (b) (5-6) (c)
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 4
Date: Jun 6, 2018
Visit Reason
The inspection was a resurvey conducted on 6/4, 6/5, and 6/6/2018 at an assisted living facility to evaluate compliance with nursing delegation, medication administration, disaster preparedness, infection control, and tuberculosis screening regulations.
Findings
The facility failed to ensure licensed nurse delegation for nursing procedures such as blood glucose monitoring, checking for bruit, and dialing insulin dosage 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 screening guidelines for residents and new employees.
Deficiencies (4)
Failure to ensure licensed nurse delegation for blood sugar monitoring and checking for bruit to certified medication aides.
Failure to ensure licensed nurse delegation for dialing insulin dosage on an insulin pen to certified medication aides.
Failure to ensure quarterly review of the facility's emergency management plan with employees and residents.
Failure to comply with tuberculosis screening guidelines for residents and new employees.
Report Facts
Census: 19
Sampled residents: 3
Sampled certified medication aides: 4
New employee records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Administrator and Certified Medication Aide | Named in findings related to lack of nurse delegation and emergency preparedness |
| Licensed nursing staff B | Licensed Nurse | Reported on tuberculosis testing documentation |
| Certified staff D | Certified Medication Aide | Named in findings related to lack of nurse delegation and tuberculosis testing |
| Certified staff E | Certified Medication Aide | Named in findings related to lack of nurse delegation and tuberculosis testing |
| Certified staff F | Certified Medication Aide | Named in findings related to lack of nurse delegation |
| Housekeeping staff C | Housekeeping Staff | Named in findings related to tuberculosis testing |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 25, 2018
Visit Reason
An offsite revisit survey was conducted on 04/25/2018 for all previous deficiencies cited on 01/09/2018 to verify correction of deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the alleged compliance date of 02/08/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Feb 8, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection report dated 2018-01-09. It outlines corrective actions, systematic changes, and monitoring plans to address cited deficiencies.
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 management including expired medications and lab monitoring, kitchen sanitation issues, infection control practices, and facility maintenance such as flooring integrity.
Deficiencies (11)
Failure to accommodate resident #2's smoking privileges during inclement weather.
Nutritional care plan for resident #9 was outdated and required revision.
Failure to respect resident bathing preferences and proper documentation of refusals.
Failure to document and assess bruising for resident #26.
Improper transfer techniques and fall prevention interventions for residents at risk.
Failure to note and act upon dietary orders and Registered Dietician recommendations timely.
Expired medications found in medication supply for residents #1, 4, 8, and 15.
Failure to monitor medications requiring laboratory testing and document black box warnings.
Unsanitary kitchen conditions including food debris, grease, and dust on multiple surfaces and equipment.
Infection control issues including unlabeled personal care items and improper handwashing/glove use.
Flooring in the kitchen requiring repair and replacement.
Report Facts
Residents with expired medications: 4
Frequency of monitoring audits: 3
Frequency of skin integrity audits: 3
Frequency of medication cart audits: 1
Frequency of medication lab monitoring audits: 3
Frequency of resident bathing audits: 3
Frequency of resident care plan audits: 2
Frequency of transfer technique audits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse #11 | Licensed Nurse | Given verbal counseling and re-education related to failure to document resident #26’s bruising. |
| Social Services Director | Social Services Director (SSD) | Met with resident #2 regarding smoking accommodations and involved in monitoring compliance. |
| DON | Director of Nursing | Responsible for re-education, monitoring, and reporting related to multiple deficiencies including care plans, medication management, skin integrity, infection control, and bathing preferences. |
| Laundry Supervisor | Laundry Supervisor | Responsible for re-education of laundry staff and reporting on infection control practices. |
| Maintenance Director | Maintenance Director | Responsible for monitoring and maintaining floor integrity and reporting to QA Committee. |
| Consultant Pharmacist | Consultant Pharmacist (RPH) | Conducted medication chart audits and ensured medications with lab monitoring and black box warnings were properly documented. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 10
Date: Jan 9, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint investigation numbers.
Complaint Details
The inspection included multiple complaint investigations identified by numbers 105588, 108381, 110952, 111823, 113870, 119259 and 121252.
Findings
The facility was found deficient in multiple areas including failure to accommodate a resident's smoking needs during inclement weather, failure to revise care plans timely, failure to provide timely bathing, failure to monitor and follow up on nutritional status, failure to monitor and dispose of expired medications, failure to identify medication irregularities, failure to prevent accidents, failure to maintain sanitary food preparation and storage, failure to maintain infection control practices, and failure to maintain a safe and sanitary environment.
Deficiencies (10)
Failed to provide reasonable accommodation of resident's smoking needs during inclement weather.
Failed to review and revise care plans timely for nutrition and falls.
Failed to provide bathing services in a timely manner for a resident.
Failed to monitor and follow up on nutritional status and dietician recommendations.
Failed to monitor and dispose of expired medications for multiple residents.
Failed to identify irregularities related to annual lab work and black box warning for medications.
Failed to follow annual orders for lab work and failed to monitor black box warning for medication.
Failed to provide sanitary food preparation and storage in the kitchen.
Failed to maintain laundry equipment and failed to store resident care equipment properly to prevent infections; failed to ensure proper handwashing after glove use and between resident contact.
Failed to maintain kitchen floor integrity and cleanliness.
Report Facts
Residents with smoking needs: 2
Days without shower: 11
Days without shower: 7
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
Expired medications: 6
Fall risk score: 16
Fall risk score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Direct Care Staff | Named in failure to use gait belt during resident transfer and failure to wash hands after glove use. |
| Staff K | Direct Care Staff | Named in failure to wash hands after glove use and leaving resident unattended. |
| Staff L | Direct Care Staff | Named in failure to wash hands after glove use. |
| Staff G | Direct Care Staff | Reported resident's poor intake and lack of awareness of bruises. |
| Staff D | Licensed Nursing Staff | Reported expectations for handwashing and verified lack of bruise monitoring. |
| Staff C | Licensed Nursing Staff | Verified missing lab work and lack of BBW in care plan. |
| Staff H | Dietary Staff | Reported on nutritional risk meetings and cleaning issues in kitchen. |
| Staff T | Laundry Staff | Reported broken laundry bins that could not be sanitized. |
| Staff U | Laundry Staff | Confirmed broken laundry bins and need for replacement. |
| Staff P | Direct Care Staff | Reported resident confusion and fall history. |
| Staff Q | Direct Care Staff | Reported resident confusion and lack of memory about fall. |
| Administrative Staff B | Administrative Nursing Staff | Reported on fall notification procedures and lack of care plan update after fall. |
| Administrative Staff A | Administrative Staff | Reported on laundry bin replacement and kitchen floor condition. |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 3, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all cited 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 as of 03/22/2017.
Deficiencies (3)
Deficiency related to regulation 483.12(a)(3)(4)(c)(1)-(4)
Deficiency related to regulation 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Report Facts
Date corrections completed: Mar 22, 2017
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 3
Date: Mar 1, 2017
Visit Reason
Complaint investigation #111819 regarding allegations of abuse, neglect, exploitation, or mistreatment related to falls and failure to report to the state agency.
Complaint Details
The complaint investigation #111819 focused on allegations of abuse, neglect, exploitation, or mistreatment related to falls and failure to report to the state agency. The facility failed to thoroughly investigate and report as required.
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. One resident experienced repeated falls resulting in hospitalization with a head injury. The facility also failed to provide adequate supervision and assistive devices to prevent repeated falls for other residents.
Deficiencies (3)
Failed to thoroughly investigate falls and report to state agency following a fall with head injury requiring sutures.
Failed to review and revise care plans following falls to prevent further falls.
Failed to provide adequate supervision and assistive devices to prevent repeated falls.
Report Facts
Resident census: 34
Residents sampled: 4
Fall risk assessment scores: 14
Fall risk assessment scores: 20
Fall risk assessment scores: 19
Fall risk assessment scores: 21
Fall risk assessment scores: 28
Laceration size: 1.5
Hematoma size: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Verified that fall investigations should identify cause and include interventions to reduce risk of further falls. | |
| Licensed nursing staff C | Reported resident receiving shower before hospital transfer and observed hematoma. | |
| Licensed nursing staff D | Assisted with assessing resident and noted vital signs and condition. | |
| Licensed nursing staff E | Reported resident's pain medication decrease and close monitoring before falls. | |
| Direct care staff H | Reported resident required help with everything but tried to be independent; unaware of falls. | |
| Direct care staff I | Reported witnessing resident falls and assisted resident back to bed. | |
| Direct care staff N | Reported toileting assistance offered every 1.5 to 2 hours; resident lacked specific toileting plan. | |
| Direct care staff P | Found resident on floor after falls; assisted resident and reported staff actions. | |
| Administrative staff A | Reported resident removed pressure sensitive alarms which became ineffective. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 1, 2017
Visit Reason
An abbreviated survey was conducted on March 1, 2017, by the Kansas Department for Aging and Disability Services 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. Due to 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 effective March 23, 2017.
Deficiencies (1)
Deficiencies found at a level of actual harm that is not immediate jeopardy requiring corrections
Report Facts
Denial of payment effective date: Mar 23, 2017
Timeframe for substantial compliance: 6
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions regarding the matter and informal dispute resolution |
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
Investigation of complaint #102286 found the resident exited the facility without staff knowledge, placing the resident in immediate jeopardy. The resident was found by staff on meal break. The facility had not identified the resident as an elopement risk and the care plan did not address elopement risk. The resident scored very low risk on the wandering risk tool at admission. The facility implemented corrective actions including staff in-service, elopement books, increased supervision, and environmental changes.
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 unharmed and the facility's investigation confirmed lapses in supervision and care planning related to elopement risk.
Deficiencies (1)
Failure to provide adequate supervision for a resident who eloped from the facility.
Report Facts
Census: 28
Distance resident ambulated: 0.2
Temperature: 93.9
Wandering risk tool score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Interviewed regarding resident supervision and assessment after elopement | |
| Administrative staff A | Interviewed about resident being found outside the facility | |
| Corporate nurse G | Interviewed about resident being found outside the facility | |
| Direct care staff E | Last staff to see resident inside facility before elopement | |
| Administrative nursing staff C | Assessed resident upon return after elopement |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 13, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Winfield Senior Living.
Complaint Details
This plan of correction is linked to a complaint investigation at Winfield Senior Living, revised on 07/13/2016.
Findings
The plan indicates that past noncompliance issues identified under tags F0000 and F323-J required no plan of correction as they were past noncompliance.
Deficiencies (2)
Past noncompliance: no plan of correction required.
Past noncompliance: no plan of correction required.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 30, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected and to confirm the date such corrective action was accomplished.
Findings
The report confirms that the previously identified deficiency with regulation 483.25(h) was corrected as of 06/30/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency related to regulation 483.25(h) corrected
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 failure to provide adequate supervision to a resident at risk for elopement.
Complaint Details
The complaint investigation found that the facility did not adequately supervise resident #01, who eloped twice without staff knowledge. Licensed staff failed to report or document the elopement as required by facility policy. The resident was cognitively impaired and at risk for elopement.
Findings
The facility failed to provide adequate supervision for one resident who exited the facility without staff knowledge on two occasions. The resident had Alzheimer's disease with severe behavior problems and was identified as an elopement risk. Despite interventions, the resident eloped twice, and staff failed to properly document and report the incidents.
Deficiencies (1)
Failure to provide adequate supervision to prevent resident elopement.
Report Facts
Resident census: 31
Sampled residents for elopement: 3
Elopement incidents: 2
Date admitted: May 13, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative licensed nurse B | Administrative Licensed Nurse | Documented verbal corrective action for licensed charge nurse C regarding failure to report elopement. |
| Licensed charge nurse C | Licensed Charge Nurse | Failed to report or document resident elopement as required. |
| Administrative staff A | Administrative Staff | Reported facility interventions following elopement and noted 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 the Medicare and/or Medicaid program.
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, and the facility was found to be in substantial compliance effective June 30, 2016.
Deficiencies (1)
'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 the contact person regarding the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 31, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to resident elopement risks.
Complaint Details
This Plan of Correction is related to a revised complaint investigation identified as Winfield Sr Living revised complaint 06152016.
Findings
The facility identified a resident who transferred to a locked memory unit and reviewed other residents at risk of elopement. The facility reviewed and updated its Elopement Policy and Procedure and initiated a Performance Improvement Project to monitor corrective actions.
Deficiencies (1)
Resident #01 transferred to a facility with a locked memory unit due to elopement risk.
Report Facts
Compliance date: Jun 30, 2016
Wandering assessment score threshold: 9
Performance Improvement Project monitoring duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Diehl | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 5, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.15(h)(2), 483.25(l), and 483.60(c) were corrected as of 05/05/2016.
Deficiencies (3)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.60(c)
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 deficiencies related to environmental cleanliness and odor control, as well as monitoring and assessment of residents on antipsychotic medications using the AIMS score and blood pressure parameters to prevent unnecessary medication use.
Deficiencies (3)
Resident's soiled chair was removed, room deep cleaned and carpet steam cleaned; daily resident checks for odor monitoring implemented.
Facility will assess AIMS score for antipsychotic use and report abnormal blood pressures to physicians; weekly reports to identify new antipsychotic medications.
Follow up with consultant pharmacist recommendations to provide AIMS assessments for antipsychotic use; weekly monitoring and reporting to QAPI Committee.
Report Facts
Dates of cleaning and inspections: Cleaning on 4/23/16 and 4/26/16; inspection on 4/29/16
Date of AIMS test: AIMS test completed on resident #1 on 4/24/16
Date blood pressures sent to physician: Blood pressures sent on 4/26/16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Diehl | LNHA (Interim) | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 25
Deficiencies: 3
Date: Apr 20, 2016
Visit Reason
The inspection was a health resurvey to assess compliance with previously identified deficiencies related to housekeeping, maintenance, and medication management.
Findings
The facility failed to maintain a sanitary environment in one resident's room due to a persistent strong urine odor. Additionally, the facility did not adequately monitor and report on the use of antipsychotic medications for one resident, including failure to perform timely AIMS assessments and to notify the physician of abnormal blood pressure readings.
Deficiencies (3)
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, odor-free resident room.
Failed to assess the AIMS score for antipsychotic use and to report abnormal blood pressures for one resident, risking adverse medication reactions.
Failed to follow up on consultant pharmacist's recommendation to provide an AIMS assessment for antipsychotic use to prevent adverse reactions.
Report Facts
Census: 25
Residents in sample: 11
Blood pressure readings out of parameters: 3
Behavior symptom log days with behaviors: 15
Inspection Report
Deficiencies: 1
Date: Apr 20, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm and are not 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)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced in relation to the survey findings and plan of correction acceptance. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 19, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal 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 an 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Effective date for denial of payments: May 19, 2016
Provider agreement termination date: Aug 19, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and involved in enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 20, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.25(c) and 483.75(g) were corrected by 09/15/2015. No uncorrected deficiencies remain as of the revisit date.
Deficiencies (2)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.75(g)
Report Facts
Deficiencies corrected: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 20, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies related to various regulatory requirements were corrected as of 10/10/2015, with no uncorrected deficiencies remaining at the time of this revisit.
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Oct 10, 2015
Visit Reason
This document is a Plan of Correction submitted by Winfield Senior Living in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including housekeeping and maintenance issues, pain management practices involving hot packs, care plan revisions for residents with weight loss, monitoring of bowel movements and PRN medication administration, and medication expiration monitoring.
Deficiencies (5)
Housekeeping and maintenance services to maintain sanitary, orderly, and comfortable interior in identified halls.
Use of hot packs for pain management no longer utilized and care plans updated accordingly.
Care plan revisions to ensure alignment with physician orders related to weight loss and monitoring by interdisciplinary team.
Monitoring of residents' bowel movements and administration of PRN medications as ordered by physician.
Disposal of expired medications and monitoring of medication expiration dates by Central Supply Clerk.
Report Facts
Corrective action completion date: Oct 10, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J Stephenson | Executive Director | Submitted the Plan of Correction |
| Director of Nursing | Monitors care plan implementation and reviews bowel records | |
| Central Supply Clerk | CMA | Monitors expiration dates of stock medications |
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 (#89034) related to housekeeping, care planning, medication administration, and treatment practices.
Findings
The facility failed to maintain a sanitary environment, develop individualized care plans for pain management, adequately monitor nutritional supplement intake, provide safe treatment with warm moist packs, monitor bowel movements and administer PRN medications as ordered, and properly manage medication expiration dates.
Deficiencies (8)
Failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in 2 of 3 halls.
Failed to develop an individualized comprehensive plan of care for use of a warm moist pack for pain relief for 1 of 15 residents sampled.
Failed to review and revise the plan of care to ensure implementation and adequate monitoring of supplement intake for 1 of 3 residents sampled for nutrition.
Failed to provide appropriate treatment related to the use of a warm moist pack resulting in a 1st degree burn for 1 resident.
Failed to ensure implementation and adequate monitoring of supplement intake for 1 resident with weight loss.
Failed to ensure adequate bowel monitoring and administration of PRN medication per physician orders for 1 resident.
Pharmacist failed to identify drug irregularities related to monitoring of bowel movements and use of as needed medication for constipation for 1 resident.
Failed to monitor expiration dates of stock medications and discard expired medications in a timely manner.
Report Facts
Resident census: 28
Resident sample size: 15
Weight measurements: 97
Weight measurements: 104.8
Burn size: 4.5
Burn size: 8.9
Reddened area size: 3.7
Reddened area size: 6.3
Medication expiration dates: 8
Medication expiration dates: 6
Medication expiration dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative nursing staff | Provided statements regarding care plan updates and medication administration |
| Staff C | Maintenance staff | Commented on housekeeping and maintenance issues |
| Staff D | Housekeeping/Laundry staff | Provided observations on facility cleanliness |
| Staff H | Licensed nursing staff | Provided statements regarding warm moist pack injury |
| Staff Q | Licensed nursing staff | Provided statements regarding care plan and injury |
| Staff R | Licensed nursing staff | Described administration of warm moist pack without physician order |
| Staff S | Direct care staff | Observed reddened area from warm moist pack |
| Staff J | Consultant staff | Provided statements regarding nutritional supplement intake |
| Staff G | Licensed nursing staff | Provided statements regarding nutritional supplement documentation |
| Staff L | Direct care staff | Provided statements regarding nutritional supplement intake |
| Staff M | Dietary staff | Provided statements regarding nutritional supplement documentation |
| Staff E | Direct care staff | Provided statements regarding bowel protocol |
| Staff N | Direct care staff | Provided statements regarding medication expiration monitoring |
| Staff Z | Consultant staff | Reviewed medication administration records and failed to identify irregularities |
Inspection Report
Enforcement
Deficiencies: 1
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 (DPNA) will be imposed effective September 29, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Deficiencies found at 'E' level severity
Report Facts
Denial of Payment effective date: Sep 29, 2015
Timeframe for termination recommendation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed letter and 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.
Complaint Details
This plan of correction is related to a complaint investigation at Winfield Senior Living Community.
Findings
The plan addresses deficiencies related to skin condition assessments and nursing staff training on shower sheets and skin assessments. It also clarifies the role of a corporate consultant pending licensure.
Deficiencies (2)
Failure to properly assess residents #3 and #4 and other residents for skin conditions and incomplete shower sheets.
Use of a corporate consultant who is not yet licensed as a nurse or administrator in Kansas.
Report Facts
Date of correction: Sep 15, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Submitted the Plan of Correction | |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Staff D | Frontline Management Consultant | Corporate consultant mentioned in plan of correction |
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 26, 2015
Visit Reason
The visit was conducted to complete an Abbreviated survey on August 19, 2015, and a Life Safety Code survey on August 26, 2015, to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The Life Safety Code survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Nov 19, 2015
Provider agreement termination date: Feb 19, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process and related to enforcement actions. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey and enforcement process. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Aug 19, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#90257) to assess the facility's compliance with treatment and services to prevent and heal pressure sores and to evaluate employment of qualified professional staff.
Complaint Details
The visit was triggered by complaint investigation #90257. The complaint involved concerns about pressure ulcer care and staffing qualifications.
Findings
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure sores for two residents with pressure ulcers, including inadequate wound assessment, documentation, and inconsistent use of preventive devices. Additionally, the facility failed to employ consultant staff with a current Kansas nursing license as required by state law.
Deficiencies (2)
Failure to provide necessary treatment and services to promote healing and prevent new pressure sores for residents #3 and #4, including inadequate wound assessment and documentation.
Failure to employ qualified consultant staff with a current Kansas nursing license.
Report Facts
Census: 32
Pressure ulcer measurements: 3
Pressure ulcer measurements: 1
Braden scores: 13
Braden scores: 12
Braden scores: 11
Braden scores: 13
Braden scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant staff D | Interim Director of Nursing (planned) | Named in relation to failure to have a current Kansas nursing license. |
| Licensed administrative staff B | Provided statements regarding wound care and staffing qualifications. | |
| Licensed nursing staff L | Physician's licensed nursing staff | Reported no evidence of communication between physician and facility regarding wound care. |
| Licensed nursing staff M | Provided written statement about initial wound discovery and treatment. |
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 noncompliance with F314, Pressure Ulcers. Enforcement remedies including denial of payment for new Medicare and Medicaid admissions were recommended due to failure to achieve substantial compliance.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Report Facts
Denial of Payment for New Admissions 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 in a complaint investigation at Winfield Senior Community ALF.
Complaint Details
This plan of correction is related to a complaint investigation at Winfield Senior Community ALF.
Findings
The plan addresses resolved and ongoing issues including a resident's wound resolution and updates to a service plan for medication-related bruising risk, with new documentation and monitoring procedures established for Certified Medication Aides and Licensed Nurses.
Deficiencies (2)
Resident #3 wound is resolved.
Resident #5 service plan updated to include use of medication that can cause increased bruising; skin monitored weekly with interventions as needed.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: May 22, 2015
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected at Winfield Senior Living Community.
Findings
The revisit inspection confirmed that the previously cited deficiency identified as S3171 under regulation 26-41-204 (i) was corrected as of 05/22/2015.
Deficiencies (1)
Deficiency identified as S3171 under regulation 26-41-204 (i)
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 concerns about inadequate nursing assessments after resident injuries.
Complaint Details
Complaint investigation #85108 focused on inadequate nursing assessments following resident injuries and bruising. The complaint was substantiated by findings of delayed and missing assessments and documentation.
Findings
The facility failed to provide adequate nursing assessments for 2 of 4 residents reviewed (#3 and #5) following injuries and bruising. Licensed nursing staff did not routinely assess wounds or bruises, resulting in delayed or absent documentation and monitoring.
Deficiencies (2)
Failure to provide adequate nursing assessments for residents following injuries, including a 10-day delay in wound assessment for resident #3.
Failure to ensure routine skin assessments for resident #5 with multiple bruises, lacking documentation 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: 12
Date: Apr 28, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report documents that all previously identified deficiencies listed on the CMS-2567 have been corrected by 03/23/2015, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (12)
Deficiency related to regulation 483.10(c)(2)-(5)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(g)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.25(m)(1)
Deficiency related to regulation 483.25(m)(2)
Deficiency related to regulation 483.30(e)
Deficiency related to regulation 483.60(a),(b)
Report Facts
Deficiencies corrected: 12
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 in a prior inspection report. It outlines corrective actions to address various compliance issues.
Findings
The plan details multiple corrective actions including staff training on root cause analysis, changes to resident funds management, maintenance and housekeeping improvements, fall prevention measures, infection control education, medication administration audits, and updated care plan procedures.
Deficiencies (13)
Statement of deficiencies to be reviewed by Quality Assurance committee and staff training on Root Cause Analysis.
Facility bank account for resident funds changed to interest bearing account and petty cash procedures updated.
Maintenance issues addressed including removal of incontinent briefs from bathroom floor, ceiling spot checks, tile repairs, carpet cleaning, and replacement of toilet paper holder.
Resident moved closer to nurse station; fall prevention measures updated including care plan change forms and equipment checks.
Guidelines implemented for neurological flow sheets after unwitnessed falls based on BIMS scores.
Staff education on catheter care and infection prevention; infection logs maintained and reviewed.
Education on treatment guidelines to prevent aspiration and dehydration for residents with feeding tubes.
Fall and incident packet updates including care plan change forms and weekly equipment checks.
Weekly blood pressure monitoring guidelines implemented with audits and staff education.
Certified Medication Aides educated on medication administration, no crush list, and competency checklists.
Audit of Medication Administration Records completed; new guidelines to prevent agency nurses from final medication checks.
Staff education on completing required staffing forms with monitoring and compliance reviews.
Education on updated pharmacy medication ordering guidelines and monitoring medication availability.
Report Facts
Date of plan completion: Mar 24, 2015
Date of staff training on Root Cause Analysis: Mar 19, 2015
Date of wheelchair brake repair: Feb 18, 2015
Date of medication audit: Feb 26, 2015
Date of toilet paper holder replacement: Feb 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Goodman | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Date: Feb 26, 2015
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services 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, resulting in enforcement remedies including denial of payment for new Medicare admissions effective May 26, 2015, until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Most serious deficiency found to be an 'F' level
Report Facts
Months until recommended termination if noncompliance persists: 6
Denial of payment effective date: May 26, 2015
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Goodman | Administrator | Named as facility administrator |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
| Joe Ewert | Commissioner | Recipient of informal dispute resolution requests |
| Janice VanGotten | Regional Manager | Copied on the letter |
| Audrey Sunderraj | Director | Copied on the letter |
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, neurological assessments after falls, urinary catheter care, feeding tube management, fall prevention and supervision, medication administration, nurse staffing posting, and pharmaceutical services.
Deficiencies (12)
Failed to manage residents' personal funds in an acceptable accounting manner including failure to deposit funds in an interest bearing account and use of residents' trust fund monies for petty cash.
Failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 2 of 3 resident hallways.
Failed to review and revise care plans for 2 sampled residents who had experienced falls.
Failed to assess neurological status following 3 of 6 falls with head injury or unwitnessed for one resident.
Failed to provide urinary catheter care in a manner to prevent urinary tract infections for one resident with a urinary catheter.
Failed to provide appropriate treatment and services to prevent aspiration and dehydration for one resident with a feeding gastrostomy tube, including failure to check tube placement prior to medication administration and failure to provide adequate free water as ordered.
Failed to ensure adequate supervision and assistive devices to prevent accidents for 2 residents, including failure to repair a broken wheelchair brake and failure to ensure functioning fall alarms.
Failed to ensure adequate blood pressure monitoring related to administration of antihypertensive medication for one resident.
Failed to ensure medication administration error rate less than 5%, with 2 medication errors observed for one resident including crushing a medication that should not be crushed and failure to check blood pressure prior to administration.
Failed to ensure one resident remained free of significant medication errors, including failure to administer ordered Prozac for 24 days and administration of potassium supplement while also administering medication to lower potassium level.
Failed to maintain posted daily nurse staffing information for at least the last 18 months as required by state law.
Failed to provide pharmaceutical services to meet the needs of residents by failing to provide medications for administration in a timely manner for two residents, including delayed administration of Kayexalate and failure to provide pain medication as ordered.
Report Facts
Resident census: 30
Residents with funds managed: 29
Total monies in resident trust fund account: 14226.85
Petty cash fund amount: 200
Falls for resident #8: 6
Fall risk assessment score: 21
Medication administration opportunities observed: 29
Medication errors observed: 2
Medication error rate: 6.89
Missed Prozac doses: 24
Delayed medication administration: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Business Office Staff | Reported trust fund account failed to have interest allocated and petty cash fund monies were withdrawn from resident trust fund |
| Administrative Staff A | Interviewed regarding housekeeping and maintenance issues and fall interventions | |
| Maintenance Staff Q | Interviewed regarding maintenance concerns | |
| Licensed Staff E | Reported resident was a fall risk and described fall interventions | |
| Direct Care Staff D | Reported motion sensor alarm batteries were not working | |
| Direct Care Staff J | Reported resident was a fall risk and described alarms used | |
| Licensed Staff L | Reported resident had a fall with injury | |
| Direct Care Staff S | Assisted resident in wheelchair and reported wheelchair brake was broken | |
| Licensed Staff G | Observed crushing medications and failed to check blood pressure prior to administration | |
| Consultant Pharmacy Staff F | Reported facility had a list of medications that could be crushed and advised staff on medication delivery | |
| Licensed Administrative Staff B | Verified medication errors and fall interventions |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 26, 2015
Visit Reason
The licensure resurvey of the facility was conducted to assess compliance for 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 by the State Fire Marshal's Office to determine if the facility was in compliance 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 that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Apr 9, 2015
Provider agreement termination date: Jul 9, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Goodman | Administrator | Facility administrator named in the report header |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
| Joe Ewert | Commissioner | Mentioned in carbon copy (c:) |
Inspection Report
Plan of Correction
Deficiencies: 1
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, addressing compliance issues related to resident care and assessments.
Findings
The plan outlines corrective actions including updated dental assessments for Resident #19, education of licensed nurses on oral/dental assessments and short term care plan approaches, implementation of these assessments for all residents, and ongoing audits to ensure compliance and follow-up.
Deficiencies (1)
Failure to perform updated dental assessment and care planning for Resident #19
Report Facts
Complete Date: Sep 2, 2014
Audit frequency: 1
Audit frequency: 6
Education date: Aug 19, 2014
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 2, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the deficiencies related to regulations 483.20(d)(3), 483.10(k)(2), and 483.25 were corrected as of 09/02/2014.
Deficiencies (2)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 2
Date: Aug 5, 2014
Visit Reason
This inspection was a Health Resurvey conducted to assess compliance with care planning and treatment requirements following previous findings.
Findings
The facility failed to review and revise the plan of care for one resident (#19) regarding assessment and treatment of an oral wound. The resident had a 3 cm sore on the upper gum related to denture use, with inadequate follow-up, treatment, and documentation. The resident's medical record lacked an oral/dental assessment and timely treatment for the oral lesion.
Deficiencies (2)
Failed to review and revise the plan of care to include assessment and treatment of an oral wound for resident #19.
Failed to adequately assess and provide timely treatment for an oral lesion for resident #19.
Report Facts
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 | Reported on care plan compliance and oral wound follow-up |
| Staff E | Activity Staff | Reported resident's request for dentures and mouth sores |
| Staff F | Direct Care Staff | Reported resident's independence and denture use |
| Staff G | Direct Care Staff | Reported current sore in resident's mouth |
| Staff C | Licensed Nursing Staff | Unaware of resident's mouth sores but recalled resident hitting face |
| Staff B | Administrative Nursing Staff | Described findings of canker sore and instructions to keep dentures out |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 5, 2014
Visit Reason
A Health survey was conducted on August 5, 2014, by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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, resulting in a finding of substantial compliance effective September 2, 2014.
Deficiencies (1)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter regarding the survey findings and plan of correction acceptance. |
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 was in 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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Deficiencies found at 'E' level, pattern, 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
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tom Anderson | Administrator | Facility administrator named in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner | Mentioned in the carbon copy line. |
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Mar 24, 2014
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at the facility.
Findings
The report documents that all previously reported deficiencies have been corrected as of 02/21/2014.
Deficiencies (4)
Regulation 26-41-205 (a) (1)
Regulation 26-41-205 (h)
Regulation 26-41-206 (e) (1)
Regulation 28-39-256
Report Facts
Correction completion date: Feb 21, 2014
Inspection Report
Follow-Up
Deficiencies: 12
Date: Mar 24, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report shows that all previously cited deficiencies were corrected by 02/21/2014 as documented by the correction completion dates for each deficiency.
Deficiencies (12)
Deficiency related to regulation 483.15(h)(6)
Deficiency related to regulation 483.15(h)(7)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(a),(b)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.75(o)(1)
Report Facts
Deficiencies corrected: 12
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Feb 21, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a prior statement of deficiencies, outlining corrective actions to address identified compliance issues.
Findings
The Plan of Correction 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, and quality assurance improvements. Audits and staff in-services are scheduled to ensure compliance by February 21, 2014.
Deficiencies (10)
Windows will be checked and sealed; thermometers placed in resident rooms to monitor temperature.
Noise reduction measures including protective mats and headsets for residents.
Individualized toileting plans and coordination of Hospice services updated and monitored.
Care plans updated for turning/repositioning and fall prevention; daily and weekly incident reviews.
Use of Diet Notification Order and care alert sheets for pressure ulcer management; staff education and audits.
Blood glucose testing and documentation procedures implemented with staff education and audits.
Infection control program monitoring and reporting with staff education and audits.
Quality assurance committee training and audits to address quality of care and life concerns.
Dietary cleaning procedures updated with audits and staff in-service.
Clarification of physician orders for blood sugar and insulin parameters with staff education and audits.
Report Facts
Audit frequency: 6
Audit frequency: 1
Compliance date: Feb 21, 2014
Staff in-service date: Feb 5, 2014
Education date: Feb 4, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Anderson | Administrator | Submitted the Plan of Correction. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 21, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection, outlining corrective actions to achieve substantial compliance.
Findings
The plan addresses multiple deficiencies including medication self-administration assessments, proper refrigerator use for medications, cleaning procedures in the kitchenette, and water heater temperature adjustments. The facility outlines education, audits, and corrective measures to ensure compliance by February 21, 2014.
Deficiencies (4)
Resident medication self-administration assessments not consistently completed.
Medication refrigerator improperly used for staff food/beverages.
Kitchenette cleaning deficiencies including steam table backsplash, cleaning lists, and drying area improvements.
Water heater temperatures not within appropriate range.
Report Facts
Audit frequency: 1
Audit frequency: 6
Audit frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Thomas Anderson | Administrator | Submitted the Plan of Correction |
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, improperly stored medications, failed to maintain sanitary food storage and preparation areas, and did not maintain safe water temperatures for residents.
Deficiencies (4)
Failed to complete assessments for self-administration of medications for 2 of 3 residents reviewed.
Failed to properly store medications in a safe and secure manner for 2 residents.
Failed to ensure the food service area remained in a sanitary condition and failed to store foods in a sanitary manner.
Failed to maintain safe water temperatures for residents; water temperatures exceeded safe limits.
Report Facts
Census: 15
Insulin units: 18
Insulin units: 56
Medication syringes: 15
Water temperature: 130
Water temperature: 132.9
Water temperature: 136.8
Water temperature: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Interviewed regarding lack of self-administration assessments and medication storage | |
| Direct care staff A | Interviewed regarding medication administration and food storage observations | |
| Dietary staff O | Interviewed regarding food sanitation and cleaning schedules | |
| Maintenance staff C | Reported on hot water tank malfunction and water temperature monitoring |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 12
Date: Jan 24, 2014
Visit Reason
The inspection was a health resurvey and complaint investigation to assess compliance with regulatory requirements related to resident care, environment, and medication management.
Complaint Details
The inspection included a complaint investigation #70585.
Findings
The facility was found deficient in maintaining comfortable temperature and sound levels, developing comprehensive and individualized care plans, preventing pressure ulcers, managing medications properly including insulin administration, maintaining infection control, and ensuring effective quality assurance processes.
Deficiencies (12)
Facility failed to maintain comfortable temperature levels in 3 residents' rooms.
Facility failed to maintain comfortable sound levels on 2 of 3 halls.
Facility failed to develop individualized comprehensive care plans for residents #50 and #13.
Facility failed to review and revise care plans for residents #31 and #32 related to pressure ulcer prevention and fall prevention.
Facility failed to implement effective interventions to prevent pressure ulcers for resident #31.
Facility failed to assess and develop individualized toileting plan for resident #50.
Facility failed to complete blood glucose monitoring as ordered for resident #35.
Facility failed to administer insulin as prescribed for resident #11.
Facility failed to identify and report drug irregularities related to blood glucose monitoring and insulin administration.
Facility failed to maintain a clean and sanitary dietary department for food storage, preparation, and service.
Facility failed to maintain an infection control program to prevent development and transmission of infections.
Facility failed to maintain an effective quality assurance committee to identify and correct quality deficiencies.
Report Facts
Residents sampled: 15
Temperature in rooms: 66
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 2.4
Pressure ulcer measurements: 1
Pressure ulcer measurements: 0.5
BIMS scores: 2
BIMS scores: 3
BIMS scores: 9
BIMS scores: 12
BIMS scores: 15
Insulin administration errors: 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 issues. | |
| Consultant staff C | Reported on care plan review and infection control monitoring. | |
| Consultant staff R | Reported on missing blood sugar documentation and pharmacy review. | |
| Direct care staff Q | Reported on resident temperature and care plan interventions. | |
| Licensed nursing staff D | Reported on resident continence and insulin administration. | |
| Licensed nursing staff E | Reported on resident repositioning and insulin administration. |
Inspection Report
Follow-Up
Deficiencies: 11
Date: Aug 28, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the prior survey were corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit report shows that all previously cited deficiencies were corrected by 08/02/2013, with no uncorrected deficiencies remaining as of the revisit date.
Deficiencies (11)
Deficiency related to regulation 483.15(a)
Deficiency related to regulation 483.15(e)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.30(a)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Deficiency related to regulation 483.65
Deficiency related to regulation 483.70(h)
Report Facts
Deficiencies corrected: 11
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jul 10, 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 plan details multiple corrective actions including updating care plans, educating nursing staff, conducting audits, revising physician order procedures, improving safety and cleanliness, and ensuring adequate staffing to address deficiencies related to resident care, safety, medication management, and facility environment.
Deficiencies (9)
Failure to maintain updated care plans reflecting resident behaviors and dignity concerns
Inadequate care plans and interventions to prevent resident falls
Improper pericare/incontinent care techniques
Safety hazards including power cord placement and chemical storage
Failure to obtain and report blood pressure parameters and medication monitoring
Insufficient staffing to meet resident needs
Inadequate cleaning and sanitizing procedures in dietary and medication rooms
Failure to maintain proper sanitizing solution and laundry temperature monitoring
Poor maintenance and cleaning of mechanical and service areas
Report Facts
Audit duration: 3
Audit duration: 6
Date: Aug 2, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Anderson | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 9, 2013
Visit Reason
This revisit report documents the follow-up inspection to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency identified as S3171 under regulation 26-41-204 (i) was corrected as of 07/03/2013.
Deficiencies (1)
Deficiency identified as S3171 under regulation 26-41-204 (i)
Report Facts
Deficiency correction date: Jul 3, 2013
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 10
Date: Jul 3, 2013
Visit Reason
The inspection was an annual health facility resurvey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity, accommodation of preferences, care planning, urinary incontinence care, accident hazards, medication monitoring, infection control, staffing sufficiency, and sanitary conditions in the kitchen and laundry.
Deficiencies (10)
Failure to ensure dignity of a resident who frequently exposed their bare chest.
Failure to ensure bathing services were provided based on resident choice.
Failure to provide adequate perineal hygiene and timely toileting for residents with urinary incontinence.
Failure to maintain a safe environment free of accident hazards and failure to provide adequate supervision to prevent falls.
Failure to ensure residents remained free from unnecessary drugs including failure to monitor blood pressure and adverse drug reactions.
Failure to ensure drug regimen review by pharmacist included monitoring and acting on irregularities.
Failure to ensure clean food preparation areas and kitchenware to prevent food borne illness.
Failure to process linens properly to prevent spread of infection in laundry.
Failure to maintain a sanitary environment in multiple areas including medication room, utility rooms, mechanical rooms, and common areas.
Failure to provide sufficient nursing staff to meet residents' physical, mental, and psychosocial needs.
Report Facts
Residents present: 37
Residents reviewed: 24
Blood pressure readings: 11
Nursing staff scheduled: 1
Nursing staff scheduled: 3
Nursing staff scheduled: 4
Temperature: 140
Sanitizer concentration: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Administrative Staff | Interviewed regarding resident dignity, care planning, and medication monitoring |
| Staff C | Licensed Administrative Staff | Interviewed regarding falls investigation and care plan updates |
| Staff E | Licensed Nursing Staff | Interviewed regarding blood pressure monitoring and resident care |
| Staff G | Direct Care Staff | Observed assisting resident with toileting and behavior management |
| Staff H | Direct Care Staff | Observed assisting resident with behavior and safety |
| Staff I | Direct Care Staff | Observed assisting resident with toileting and hygiene |
| Staff K | Direct Care Staff | Interviewed and observed regarding resident care and toileting |
| Staff L | Direct Care Staff | Interviewed regarding documentation of resident behaviors |
| Staff M | Direct Care Staff | Observed assisting resident with toileting and hygiene |
| Staff O | Direct Care Staff | Interviewed regarding resident care and falls |
| Staff Q | Direct Care Staff | Interviewed regarding resident bathing preferences and falls |
| Staff R | Social Services Staff | Interviewed regarding resident bathing preferences |
| Staff T | Activity Staff | Observed assisting residents and interviewed regarding staffing |
| Staff U | Housekeeping/Laundry Staff | Interviewed regarding laundry and environmental cleaning |
| Staff V | Maintenance Staff | Interviewed regarding environmental hazards and laundry temperatures |
| Staff X | Consultant Staff | Interviewed regarding laundry sanitization and pharmacy consulting |
| Staff Y | Pharmacy Consultant Staff | Interviewed regarding medication monitoring and recommendations |
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 failure to perform neurological checks when necessary.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Good Sam Winfield 061213 Complaint.
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 to ensure compliance.
Deficiencies (1)
Failure to conduct an assessment to determine the cause of a fall and failure to ensure neurological checks when necessitated by the incident.
Report Facts
Audit frequency: 3
Audit frequency: 9
Plan of Correction completion date: Jul 3, 2013
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 5
Date: Jun 12, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#66145) regarding the facility's failure to provide care and services in accordance with standards of practice, specifically related to falls and subsequent care.
Complaint Details
Complaint investigation #66145 focused on failure to provide care and services in accordance with standards of practice related to falls and post-fall care.
Findings
The facility failed to assess the cause 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 appropriate neuro checks. Residents #2 and #3 also had falls without updated care plans or interventions. The facility did not complete neurological checks after head injuries and failed to provide care consistent with standards of practice.
Deficiencies (5)
Failure to conduct assessments to determine cause of falls and develop interventions to prevent recurrence for residents #1, #2, and #3.
Failure to complete neurological checks for resident #1 after falls with head injuries.
Resident #1's Nursing Health Service Plan was not updated to reflect falls or develop interventions to prevent recurrence.
Resident #2's Health Service Plan was not updated to reflect fall or develop interventions to prevent recurrence.
Resident #3's Health Service Plan was not updated to reflect fall or develop interventions to prevent recurrence.
Report Facts
Resident falls: 4
Census: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Reported on resident #1's falls and care provided. | |
| Licensed nursing staff E | Reported on fall assessments and neuro checks. | |
| Direct care staff C | Reported observations related to resident falls and care. | |
| Direct care staff D | Reported observations related to resident falls and care. | |
| Licensed nursing staff F | Reported on resident #1's pain and neuro checks. | |
| Physician H | Physician | Recalled call about resident fall but no further involvement. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 14, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the prior survey were corrected as of the revisit date.
Findings
The revisit report shows that all previously identified deficiencies were corrected by 01/08/2013, with no uncorrected deficiencies remaining as of the revisit date.
Report Facts
Correction completion date: Jan 8, 2013
Follow-up survey completion date: Dec 10, 2012
Inspection Report
Plan of Correction
Deficiencies: 18
Date: Jan 8, 2013
Visit Reason
This document is a Plan of Correction submitted by Good Sam Winfield in response to deficiencies identified in a prior inspection, outlining corrective actions to address various care and facility issues.
Findings
The plan details multiple corrective actions including staff education, audits, resident interviews, environmental repairs, care plan updates, and monitoring to ensure compliance with care standards related to social history, pain management, dialysis monitoring, bowel protocols, hydration, medication management, staffing, and safety.
Deficiencies (18)
Incomplete social history forms and lack of addressing lifestyle preferences in care plans.
Housekeeping and environmental issues including building foundation problems.
Failure to complete comprehensive MDS assessments timely.
Care plans not comprehensive regarding dialysis, anti-anxiety medication, contractures, and range of motion.
Inadequate bowel management protocols and documentation.
Failure to provide adequate ADL services including personal and oral hygiene.
Inadequate pressure relieving devices and repositioning to prevent pressure sores.
Lack of individualized toileting plans and reassessment of continence status.
Restorative plans not addressing range of motion and contractures adequately.
Unsafe environmental hazards such as tripping hazards in nurses' station and conference room.
Inadequate hydration management and fluid restriction order reviews.
Failure to follow pharmacy recommendations and monitor unnecessary medications.
Insufficient nursing staff to meet residents' needs and maintain quality of care.
Failure to post nurse staffing information daily.
Delays in obtaining medications due to pharmacy payment issues.
Failure to monitor and follow pharmacy recommendations for unnecessary laxatives.
Management deficiencies in ensuring dignified care, bowel monitoring, dialysis monitoring, pain management, and other resident care needs.
Quality Assurance committee not fully implementing continuous survey readiness and quality improvement processes.
Report Facts
Audit duration: 12
Resident interviews frequency: 3
Resident interviews frequency: 1
Staff education dates: Dec 19, 2012
Plan of Correction submission date: Dec 21, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Anderson | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 4, 2013
Visit Reason
This is a revisit report completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished.
Findings
The report documents that the previously cited deficiency identified by regulation 26-41-102 (a) with ID prefix S3245 was corrected as of 01/04/2013.
Deficiencies (1)
Deficiency related to regulation 26-41-102 (a)
Report Facts
Deficiency correction date: Jan 4, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 4, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection, outlining corrective actions to ensure compliance with staffing requirements in the assisted living area.
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 ongoing audits to ensure compliance.
Deficiencies (1)
Insufficient number of direct care staff or licensed nursing staff in the assisted living area at all times
Report Facts
Audit frequency: 3
Compliance target date: Jan 4, 2013
Inspection Report
Census: 41
Deficiencies: 17
Date: Dec 10, 2012
Visit Reason
The inspection included a health resurvey, an extended resurvey, and complaint investigations.
Findings
The facility was cited for multiple deficiencies including failure to provide dignified care, failure to respect resident choices, inadequate housekeeping and maintenance, incomplete comprehensive assessments, incomplete care plans, failure to provide timely pain management, inadequate dialysis monitoring, failure to prevent pressure ulcers, inadequate hydration, unsafe environment, and insufficient nursing staff.
Deficiencies (17)
Failure to provide care and treatment in a dignified manner for resident #55, including delayed pain medication and toileting assistance.
Failure to ensure resident #60 received care and services respecting their lifestyle choices, including sleep schedule.
Failure to provide adequate housekeeping and maintenance services in multiple areas including hallways, dining room, and activity room.
Failure to complete and submit a comprehensive significant change assessment for resident #4.
Failure to develop comprehensive care plans for residents #5, #52, and #10, including dialysis monitoring, psychotropic medication use, and contracture management.
Failure to ensure resident #12 received care with input into their plan and failure to revise care plan related to incontinence.
Failure to provide adequate care and assistance to maintain good personal and oral hygiene for resident #58.
Failure to prevent development of pressure ulcers for residents #58 and #6, including failure to reposition and provide pressure relieving devices.
Failure to provide individualized toileting plan for resident #12 to restore or maintain bladder function.
Failure to perform restorative range of motion services for residents #14, #10, and #2.
Failure to provide safe assistive devices and safe environment for resident #6 and failure to maintain safe environment on two hallways.
Failure to provide adequate hydration for resident #5 per physician's fluid restriction order.
Failure to follow pharmacy services and recommendations for residents #14, #15, and #20 related to monitoring bowel eliminations and laxative use.
Failure to obtain and administer physician prescribed medications in a timely manner for resident #14.
Failure to monitor and evaluate effectiveness of bowel medications for resident #14, resulting in fecal impaction and immediate jeopardy.
Failure to provide sufficient nursing staff to meet residents' physical, mental, and psychosocial needs for 6 of 9 days of the survey.
Failure to post complete nurse staffing data including second shift staffing on a daily basis.
Report Facts
Residents reviewed: 30
Residents with pressure ulcers: 3
Days resident #49 had no bowel movement: 8
Fluid intake ordered: 2000
Fluid intake provided: 1440
Bowel movements in 7 days: 13
Braden scale score: 14
Braden scale score: 15
Braden scale score: 15
Bowel movements missed: 7
Days side rails loose: 3
Days without repositioning: 3
Pain medication delay: 45
Days without lab monitoring: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nursing staff I | Licensed Nurse | Reported resident #55 pain management delay and lab monitoring issues for resident #60 |
| direct care staff N | Direct Care Staff | Assisted resident #5 after dialysis and reported care details |
| licensed nursing staff H | Licensed Nurse | Reported dialysis monitoring and pain management details for resident #5 and #55 |
| licensed nursing staff B | Administrative Nursing Staff | Reported hydration and bowel management issues, staffing concerns |
| direct care staff FF | Direct Care Staff | Reported bowel management and laxative administration issues for resident #20 |
| consultant staff HH | Consultant | Reported issues with medication documentation and laxative monitoring |
| licensed nursing staff E | Licensed Nurse | Responsible for restorative nursing program, reported resident #14 restorative care status |
| direct care staff L | Direct Care Staff | Reported restorative care activities and resident participation |
| direct care staff Q | Direct Care Staff | Reported resident #58 hygiene care and skin condition |
| maintenance staff EE | Maintenance Staff | Reported on facility maintenance issues including loose bed rails and environmental hazards |
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 at 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 and reliance on residents having lifelines or cell phones for emergency contact.
Deficiencies (1)
Failed to maintain adequate staffing at the facility as evidenced by insufficient staff on duty during observation.
Report Facts
Census: 12
Staff on duty: 4
Licensed nurse duty hours: 4
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N018006 POC P0ZT11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Complaint Details
This Plan of Correction is linked to a complaint investigation identified as 'winfield sr living complaint 03012017'.
Findings
The plan addresses deficiencies related to fall prevention, investigation of incidents to rule out abuse or neglect, and updating care plans and staff training to ensure appropriate interventions are implemented.
Deficiencies (3)
Failure to thoroughly investigate residents' incidents to rule out abuse or neglect and implement appropriate fall prevention interventions.
Failure to complete root cause analysis of falls and update care plans accordingly.
Failure to ensure medical records reflect root cause analysis and timely update of care plans after falls.
Report Facts
Complete Date: Mar 22, 2017
Residents referenced: 4
Review period: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laurala Lachman | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction |
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