WINDSOR PLACE LLC

Nursing Home Inspector

2921 W 1ST STREET
COFFEYVILLE, KS 67337
Montgomery County
Phone: 620-251-5190
Provider Number: 175290
Last Inspection: 05/11/2016

About the Nursing Home

Number of Beds: 147
Number of Residents: 128
Beds Available: 19
Percent Occupancy: 87%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

19

Facility
29

County
29

KS
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

19

2016
36

2015
17

2013

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/11/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 6/10/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/10/2016
 
Failed To: Make sure that special or therapeutic diets are ordered by the attending doctor. Pattern : Minimal 4 6/10/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/10/2016
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 6/10/2016
 

1/22/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 2/21/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/21/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 2/21/2015
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 2/21/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 2/21/2015
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 2/21/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 2/21/2015
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 2/21/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 2/21/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 2/21/2015
 

10/1/2013 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 10/31/2013
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/31/2013
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 10/31/2013
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 10/31/2013
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

12/7/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/31/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 12/31/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 12/31/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg KS State Avg
Number of Residents 128 43.50 52.13
Registered Nurses 0.81 1.31 0.82
Licensed Practical / Vocational Nurses 0.40 0.59 0.65
Certified Nursing Assistants 2.79 2.63 2.63
Total Staff Hours 4.00 4.53 4.10

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% KS State Avg%
of high risk long-stay residents with pressure ulcers 7 6 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 91 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 95 95
of long-stay residents experiencing one or more falls with major injury 4 4 4
of long-stay residents who have depressive symptoms 7 5 6
of long-stay residents who lose too much weight 3 7 7
of long-stay residents who received an antianxiety or hypnotic medication 27 22 24
of long-stay residents who received an antipsychotic medication 29 15 19
of long-stay residents who self-report moderate to severe pain 11 10 8
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 16 21 19
of long-stay residents whose need for help with daily activities has increased 13 13 16
of long-stay residents with a catheter inserted and left in their bladder 3 1 2
of long-stay residents with a urinary tract infection 10 5 5
of low risk long-stay residents who lose control of their bowels or bladder 74 44 39
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 75 78
of short-stay residents who had an outpatient emergency department visit 14 16 11
of short-stay residents who made improvements in function 72 64 70
of short-stay residents who newly received an antipsychotic medication 5 1 2
of short-stay residents who self-report moderate to severe pain 21 25 19
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 94 75 74
of short-stay residents who were rehospitalized after a nursing home admission 21 20 19
of short-stay residents who were successfully discharged to the community 54 55 55
of short-stay residents with pressure ulcers that are new or worsened 2 1 1