Ahva Care of Winfield

In the surveyor’s words

From the most serious findings on record at Ahva Care of Winfield, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident with a history of overstuffing his mouth with food was provided supervision and intervention during consumption of a peanut butter sandwich. The facility also failed to have a system in place to identify residents with swallowing precautions and failed to supervise two other residents on swallowing precautions during a meal service. This failure resulted in R1 experiencing a choking incident requiring the Heimlich maneuver and transportation to the local hospital. Hospital documentation showed R1 expired at the local hospital within an hour of the incident on February 1, 2023, at 3:55 AM. This applies to 3 of 5 residents (R1, R2, and R3) reviewed for accidents and supervision in a sample of 5. […]

• Actual harm, isolatedF686Mar 2, 2023

  Based on observation, interview, and record review the facility failed to prevent and identify an area of pressure prior to becoming a deep tissue injury, failed to implement offloading interventions, and failed to assess new pressure injuries for 2 of 6 resident (R38, R70) reviewed for pressure in the sample of 24. This failure resulted in R70 suffering three deep tissue injuries. The findings include: 1. R70's face sheet listed diagnosis including encephalopathy, kidney disease stage 3, heart failure, acute respiratory failure, bipolar disorder, adult-onset fluency disorder, and dementia. On 02/28/23 at 02:02 PM, R70 was in bed with her eyes closed and positioned to her right side. R70 had heel boots on, and her toes were exposed with no dressings. […]

• Actual harm, isolatedF711Jan 20, 2022

  Based on interview and record review the physician failed to identify, monitor, and treat an elevated blood sugar. This applies to 1 of 5 residents (R1) reviewed for change in status in a sample of 5. This resulted in R1 being hospitalized in the intensive care unit with diabetic ketoacidosis. Findings include: R1's Admission Record document R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Order Recap Report for 9/1/2021-1/31/2022 documents a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The results of the blood sugar level on this report were 211 milligrams/deciliter (mg/dl) with a normal range of 70-110. The Order Recap Report does not document any further physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF761Mar 2, 2023

  Based on observation, interview, and record review, the facility failed to store medications in a locked medication room, failed to keep narcotic medications secured with a double lock, and failed to dispose of expired insulin. These failures have the potential to affect all residents in the facility. The findings include: The Resident Census and Condition Report dated [DATE] showed 120 residents residing in the building. On [DATE] at 10:08AM, the 2nd floor medication room was reviewed with V6 (Registered Nurse). The medication refrigerator was not locked and a full bottle (30ml) of morphine belonging to R70 was locate inside the refrigerator in a plastic bag. […]

• No harm, potential for more than minimal, patternF628May 14, 2026

  Based on interview and record review, the facility failed to provide residents and/or their POA (Power of Attorney) with a bed hold notice and written documentation for the reason of transfer to the hospital.This applies to 5 of 5 residents (R1, R2, R10, R129, R138) reviewed for transfers in a sample of 30.The findings include: 1.R1's progress note dated 1/23/26 at 4:56 PM shows: NOD (Nurse on Duty) noted a change in mental status of resident during her neuro checks. (R1) appeared confused and verbalized feeling nervous. Although (R1) remained alert and orientated x 4, (R1) appeared not at her baseline behavior. Vitals shown an elevated blood pressure from baseline of BP (Blood Pressure) 158/89 and respiratory rate increased to 28 breaths per minute from baseline. […]