Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R38's face
sheet printed on 3/1/23 showed diagnoses including but not limited to respiratory failure, heart failure,
hypertension, obesity, schizophrenia, mood disorder, intellectual disabilities, and bilateral embolism and
thrombosis of lower extremity deep veins. R38's facility assessment dated [DATE] showed extensive staff
assistance needed for bed mobility, transfers, dressing, and toilet use.
Residents Affected - Few
R38's Braden Scale for Predicting Pressure Sore Risk dated 2/19/23 showed a moderate risk.
On 2/28/23 at 10:36 AM, R38 was seated in a wheelchair on the second-floor unit. R38 had yellow anti-skid
socks on and both feet were flat on the floor. R38's foot appeared to have a bandage sticking out over the
top of the sock. At 12:30 PM, R38 was in his wheelchair in the main dining room wearing the yellow socks.
His feet were flat on the floor. At 1:12 PM, R38 was in his wheelchair by the second-floor elevator. R38's
feet were bare, and his feet were flat on the floor. V6 (Registered Nurse) was questioned about the
bandage on R38's heel. V6 stated she did not know but guessed it was likely from a recent treatment.
On 3/1/23 at 8:55 AM, V11 and V12 (Certified Nurse Assistants) toileted R38 while V4 (Wound Nurse) was
present. V4 was asked to remove R38's socks and a white bandage was observed on the right heel. V4
removed the dressing. A half-dollar size split open white area with a dime size dark purple center was
observed. V4 cleansed and measured the white area and stated it was 3.8 by 4.0 centimeters. V4 said it
looked like a blister that had opened. V4 said he would classify the dark purple bruising area as a DTI
(deep tissue injury). V4 said it was approximately 25% the size of the blistered area. V4 said it was the first
time he was aware of any wounds on R38's heels. V4 said it appeared to have been caused by R38 rubbing
his heels on the floor. V4 said R38 propels himself all around the units and should have something
protecting his heels to prevent the breakdown. V4 said it should have been off-loaded as soon as it was
found. V4 said it should have been documented in the resident chart and verbally passed on between
shifts. At 9:20 AM, V4 and the surveyor reviewed R38's electronic medical record together and V4
confirmed there was no documentation of the wound to R38's right heel. V4 said resident skin should be
inspected during all care by the aides. Nurses inspect skin two times weekly on shower days. The physician
should be immediately notified of any skin changes to get treatment started and get the wound healing right
away.
On 3/2/23 at 11:30 AM, V2 (Director of Nurses) stated skin checks should be done head to toe with every
shower by the CNAs. Nurses do skin checks with every medication pass. If a resident is prone to pressure
ulcers, then it is a head-to-toe assessment. Any skin changes should be reported to the physician, family,
director of nurses and the wound care nurse right away. V2 said if skin changes are not found at an early
stage there is the potential for worsening of the wound and the risk of infection. V2 was asked to describe
the characteristics of a DTI and stated it is an area not open, dark
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
146168
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
purple, and non-blanchable. V4 was present and stated he does the initial assessment on wounds which he
did verbally for R38 with the surveyor on 3/1 and the wound care physician does the final diagnosis.
Level of Harm - Actual harm
Residents Affected - Few
On 3/2/23 at 1:10 PM, V13 (Wound Doctor) was asked to describe the characteristics of a DTI and stated it
is a purple, boggy area and may appear as a fluid filled blister. (V13 had just entered the facility and had not
yet assessed R38's heel, therefore no formal wound assessment by V13 was available.) V13 said it
important to have resident heels protected from pressure and bare feet on the floor is not ideal. V13 said it
is important to prevent pressure wounds from forming. It is easier to prevent them versus trying to heal
them later.
R38's care plan showed a focus area related to skin alterations. Interventions included: Identify/document
potential causative factors and eliminate/resolve where possible; monitor skin with care/showers; report any
signs of skin breakdown (sore, tender, red, or broken areas).
The facility's Assessment of Skin Alteration/Skin Checks Policy dated 1/2023 states under the procedure
section: 1. Skin checks should be completed at least daily for any skin alteration. 3. The Resident's doctor
should be notified of any skin alteration and obtain new orders for monitoring and treatment. Document the
orders in the medical chart.
The facility's Wound Prevention Program Policy dated 2/2022 states under the Activity, Mobility and
Positioning Interventions section: c. While in bed or in a wheelchair, resident should be turned/repositioned
at least every 2 hours and as needed. i. Off load elbows and heels using pillows as needed. k. Occupational
therapy to evaluate for wheelchair positioning as needed.
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. R70's heels were not offloaded and were in
lying on the mattress.
On 03/01/23 09:08 AM, R70 was in bed supine with the head of the bed elevated. R70 had bilateral heel
boots on with heels resting directly on the mattress. R70's heels were not offloaded. R70 did not have socks
or dressing to her feet and her toes were in direct contact with the sheet covering her. R70 was able to say
her name but was otherwise disoriented. R70 was unable to move her legs when requested.
On 03/01/23 at 01:56 PM, R70 was supine in bed. A top sheet and blanket rested directly on R70's
uncovered toes. R70's heels were not offloaded. Examination of the wounds with assistance of V4 (Wound
Nurse) showed left great toe tip had a reddened-purplish area of intact skin, right great toe tip wound
(larger than left) showed a flattened dried blood blistered area which was unopened, left heel
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Actual harm
Residents Affected - Few
had area had a discolored, non-blanchable reddened area. None of the wounds had dressings. R70's right
heel had a large, discolored area that was blanchable, and the right medial bony prominence of the right
foot had a reddened area.
On 3/2/23 at 11:04 AM, V2 (Director of Nursing/DON) said, to offload pressure we use air loss mattress,
turning frequently, and heel boots. Heel boots off load pressure to the heel. You still need to put pillows
under the lower legs to ensure the feet are off the bed. Heels should not be resting on anything. Offloading
pressure to the toes is done by using open toed boots, no tight-fitting socks and no blankets tight on the
toes. It's important to offload so the skin doesn't open. You don't want other injuries, deeper injuries, or
worsening of an injury. The key to pressure prevention is to remove pressure. If pressure is not relieved the
wound is going to open, ulcer and worsen. Other wounds may develop as well.
On 3/2/23 at 11:30 AM, V2 said I don't consider a blister a pressure ulcer. It can come from things other
than pressure.
On 3/2/23 at 1:11 PM, V13 (Wound Doctor) said ideally, yes he would expect the facility to identify areas of
pressure prior to becoming a stage 3. Ways to offload pressure from the heels may include use of a pillow
to float the heel or use offloading boots. They don't have foot cradles here but that would keep the bed
covers from rubbing the tips of R70's toes. V13 said he assessed R70 once and determined she had three
deep tissue injuries. We discussed the sheets rubbing as the cause of the DTI's. Since they don't have foot
cradles, they were going to use ABD (thick gauze pads) pads over the areas. If offloading isn't done,
wounds could deteriorate. The blisters did not have clear fluid. That's why they were DTI's. Pressure injury
prevention is better than treatment.
During the survey, V4 (Wound Nurse) said he was not certified in wound care and does not officially stage
wounds. V4 states his assessments are preliminary until confirmed by V13 (Wound Doctor). V4 does not
know V13's name.
R70's 1/25/23 facility assessment showed severe cognitive impairment extensive assistance of two plus
persons required for bed mobility, transfer, toilet use, personal hygiene, and total dependence for bathing.
R70's 1/18/23 pressure sore risk assessment showed a high risk.
The facility's weekly wound report showed R70 had three facility acquired (2/14/23) Deep Tissue Injuries
(DTI's). Noted on this report was a DTI to the right first toe, left first toe, and the left heel.
R70's 2/17/23 hospice note showed redness to the lower legs and both big toes. The facility nurse was
notified.
R70's 2/18/23 nurses note showed discoloration to the top of bilateral big toes. The nurse notified hospice.
R70's 2/18/23 nurses note showed the hospice nurse visited and recommended the facility wound nurse
assess the resident for Deep Tissue Injury (DTI) to bilateral great toes, and bilateral heels. The facility
wound nurse was updated.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
The facility's initial wound assessment by the facility was requested an a 2/20/23 Skin Evaluation was
received. This document was authored by V4 (Wound Nurse.)
Level of Harm - Actual harm
Residents Affected - Few
R70's 2/20/23 wound evaluation by V13 (Wound Doctor) showed wound #1 unstageable DTI of the right
first toe, partial thickness blood filled blister, etiology, pressure. V13 recommended to offload the wound and
place an ABD pad to the area daily. Wound #2 unstageable DTI of the left, first toe partial thickness,
etiology, pressure. V13 recommended to offload the wound and place and ABD pad over the area daily.
Wound #3 unstageable DTI of the left heel partial thickness, etiology, pressure. V13 recommended to
offload the wound and float heels while in bed.
The National Pressure Injury Advisory Panel (NPIAP) pressure injury stages showed a pressure injury is
localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a
medical or other device. The injury can present as intact or open ulcer and may be painful. The injury
occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The
tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion,
comorbidities, and condition of the soft tissue. A Deep Tissue Pressure Injury (DTPI): Persistent
non-blanchable deep red, maroon or purple discoloration- Intact or non-intact skin with localized area of
persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark
wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear
forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue
injury or may resolve without tissue loss. Do not use DTPI to describe vascular, traumatic, neuropathic, or
dermatologic conditions.
The facility's 1/2023 Assessment of Skin Alteration/Skin Checks Policy showed residents with skin
alteration will be assessed, and the physician will provide treatment. The assessment of any alteration
should be started immediately upon identification of a pressure ulcer and findings need to be documented
in the medical record. Wound assessment/measurement should be completed and documented in the
medical record upon identification and weekly until healed to reflect progress. The resident's plan of care
should be reviewed and updated as needed.
The facility's 2/2022 Wound Prevention Program showed implementation of preventative measures and/or
appropriate treatment modalities for ulcers are put into place according to the standard of care. Develop a
plan of care and implement intervention according to the resident risk factors identified. 2. Identification of
risk factors that can impact developing unavoidable ulcer or will affect healing process if resident does have
an ulcer. The following are risk factors: a. acute illness or change in condition i.e., upper respiratory
infection, pneumonia c. cognitive loss d. decreased mobility or bedfast g. edema h. elderly residents with
very dry skin and/or poor skin turgor i. ends stage disease/ terminal illness m. history of pressure ulcers. 4.
Activity Mobility and Positioning Interventions: establish an individualized turning and repositioning
schedule if the resident is immobile. If the resident is on bed, position the resident body on bed with pillows,
or other supportive devices and/or low air loss mattress to protect boney prominence susceptible to
pressure. Offload heels using pillows as needed. Elevate resident heels off the bed as indicated (e.g., place
pillows under calf (not under ankles) to raise heels off the bed, unless contraindicated due to medical
condition).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure a resident's urinary drainage bag was
positioned in a manner to prevent infection and failed to ensure a resident's urinary drainage tubing was not
in contact with the floor for 2 of 3 residents (R76, R82) reviewed for catheters in the sample of 24.
The findings include:
1. R82's face sheet lists diagnosis including multiple sclerosis, quadriplegia, urethral stricture, scoliosis,
anxiety disorder and major depressive disorder.
On 02/28/23 at 10:29 AM, R82 was in his electric wheelchair in his room. The catheter drainage bag was
lying unsecured in the footrest with both of R82's feet on top of the bag. There was a moderate amount of
urine in the bag and a moderate amount of purulent sediment was visible in the catheter tubing.
On 2/28/23 at 10:30 AM, R82 said it (the drainage bag) always slides off. R82 said he was unable to
reposition the bag himself and he would call for someone to help move it.
On 03/02/23 at 11:04 AM, V2 (Director of Nursing/DON) said R82's chair does not have many places to
hang the bag. He has run over it before. His feet should not be on top of the bag for infection prevention.
R82's care plan showed he had a suprapubic catheter due to urinary retention. Staff will assist R82 to care
for his catheter.
R82's 12/21/22 facility assessment showed he was cognitively intact, required extensive assistance of two
plus persons to physically assist with bed mobility, transfers, dressing, toilet use, and bathing.
The facility's 2001 Urinary Catheter Care Policy showed the purpose of this procedure is to prevent
catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow -Check the resident
frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.
Infection Control-Maintain clean technique when handling or manipulating the catheter, tubing, or drainage
bag.
2. The facility face sheet for R76 includes diagnoses urinary retention, benign prostatic hyperplasia with
lower urinary tract infections. The facility assessment dated [DATE] shows R76 to be cognitively intact and
requires extensive assistance of one staff for catheter care. The March 2023 POS (Physician Order Sheet)
for R76 shows an order for a supra pubic urinary catheter.
On 2/28/23 at 11:20 AM, R76 was observed wheeling himself down the hall and his catheter tubing was
dragging on the ground. At 12:15 PM R76 was observed in the dining room with his catheter tubing still on
the ground.
On 3/02/23 at 8:52 AM, V8 (Registered Nurse) said catheter tubing should not be dragging on the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
ground for infection control purposes. The tubing should be thread through the pant leg and into the dignity
bag. V8 said R76 requires help with getting transferred into his wheelchair.
On 3/02/23 at 8:57AM, V9 (Certified Nursing Assistant) said the catheter tubing should be run through the
pant leg and into the dignity bag under the wheelchair. The tubing should not be touching the ground. V9
said R76 needs help getting into his wheelchair and getting dressed.
On 3/02/23 at 9:02 AM, V2 (DON) said the catheter tubing should not be dragging on the ground for
infection control reasons. The tubing should be run through the pant leg and into the dignity bag. R76
sometimes will refuse to have the tubing done this way but the staff need to find someone to help them, so
the tubing is not dragging on the ground.
The facility policy for catheter care with a revision date of 11/2017 shows the purpose of this procedure is to
prevent catheter-associated urinary tract infections. Be sure the catheter tubing and drainage bag are below
the residents' bladder and kept off the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure oxygen was administered at the rate
the physician ordered for 1 of 1 resident (R38) reviewed for oxygen in the sample of 24.
Residents Affected - Few
The findings include:
R38's face sheet printed on 3/1/23 showed diagnoses including but not limited to acute and chronic
respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, obstructive sleep
apnea, and asthma. R38's facility assessment dated [DATE] showed extensive staff assistance needed for
bed mobility, transfers, dressing, and toilet use.
R38's order summary report shows a physician order start dated 1/11/23 for: Oxygen per nasal
cannula/face mask at 4 L/min (liters per minute) continuous every shift for SOB (shortness of breath)
related to chronic obstructive pulmonary disease. Keep oxygen saturation greater or equal to 92%
R38's progress notes showed a recent emergency room visit on 2/27/23 due to unstable oxygen saturation
levels at 78% and 85%.
On 2/28/23 at 1:14 PM, R38 was seated in a wheelchair in the hallway of the second-floor unit. R38 was
wearing oxygen via nasal cannula. The oxygen was set at 2 liters per minute.
On 3/1/23 at 8:55 AM, R38 was in the wheelchair near the men's shower room. His oxygen was running via
nasal cannula and was set at 2 liters. V4 (Wound Care Nurse) verified the setting was at 2 liters and stated
that was the correct level.
On 3/1/23 at 1:08 PM, R38 was seated in a wheelchair in the hall near the nurse station. V10 (Licensed
Practical Nurse) was asked to verify the setting on R38's oxygen and stated it was running at 2 liters.
R38's oxygen saturation summary sheet was reviewed for 3/1/23 and showed the oxygen saturation rate at
90%. The summary sheet showed a 3/2/23 rate at 91%.
On 3/2/23 at 11:37 AM, V2 (Director of Nurses) stated oxygen needs a physician's order to be given and it
is important to give it at the prescribed rate. Running oxygen too low can cause a low oxygen saturation
level and lead to other medical things. It is especially important for (R38) because of his current respiratory
issues.
The facility's undated Oxygen Administration policy states: 7. Adjust the oxygen delivery device so that it is
comfortable for the resident and the proper flow of oxygen is being administered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. An insulin pen belonging to R11 was in a cup of miscellaneous
insulin pens with an open date of [DATE] and an expiration date of [DATE]. V6 confirmed the insulin pen
was expired and should have been disposed of upon expiration. V6 stated they have always put morphine
in the refrigerator, and it hasn't been double locked that she is aware of.
On [DATE] at 10:35AM, this surveyor attempted to locate the first-floor nurse. This surveyor knocked on the
medication room door and turned the handle and was able to access the medication room without a code
or a key. V7 (Registered Nurse) arrived at the nurse's station and showed surveyor that the medication
room was not locked by accessing the medication room without a key or a code. V7 stated the medication
room should be locked so that residents are unable to access the medication room and supplies that are
located in the medication room. The refrigerator in the medication room was not locked and contained a vial
of injectable lorazepam belonging to R276.
On [DATE] at 11:05 AM, V2 (Director of Nursing) stated, The medication rooms should be locked because
there are medications in there. The lorazepam should be locked in a lock box in both medication
refrigerators. Morphine should be double locked because it is a narcotic. We used to have lock boxes in the
refrigerators so I'm not sure where they went. All medications that are expired should be disposed of upon
expiration. There is no reason why we wouldn't do that and that is our policy.
As of [DATE] at 2:00PM, The facility was unable to provide a policy related to medication storage.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146168
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ahva Care of Winfield
28 West 141 Liberty Street
Winfield, IL 60190
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to obtain consent or refusal for the influenza vaccine. This
applies to 1 of 13 residents (R119) reviewed for vaccinations in the sample of 24 and 2 residents
(R54,R121) outside of the sample.
Residents Affected - Some
The findings include:
1) R119's electronic face sheet printed on 3/2/23 showed R119 was admitted to the facility on [DATE].
R119's immunization records as of 3/2/23 did not show R119 had refused the influenza vaccination.
The facility's vaccination log showed, consent needed for R119's influenza vaccination.
2) R54's electronic face sheet printed on 3/2/23 showed R54 was admitted to the facility on [DATE].
R54's immunization records as of 3/2/23 did not show R54 had refused the influenza vaccination.
The facility's vaccination log showed, consent needed for R54's influenza vaccination.
3) R121's electronic face sheet printed on 3/2/23 showed R121 was admitted to the facility on [DATE].
R121's immunization records as of 3/2/23 did not show R121 had refused the influenza vaccination.
The facility's vaccination log showed, consent needed for R121's influenza vaccination.
On 3/2/23 at 12:14PM, V3 (Infection Preventionist) stated, If a resident refuses a vaccination, we document
that in the immunization record and would make a progress note. If we are waiting on a consent, then those
conversations should be documented in a progress note as well. We should be re-attempting to speak with
the resident and Power of Attorney if we are just waiting on a consent or refusal to be determined. Upon
admission, the admitting nurse should be having the initial conversation with resident's and their families
regarding immunizations and documenting that conversation in progress notes.
The facility's policy titled, Influenza Vaccine dated November 2015 showed, All residents who have no
medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and
promote the benefits associated with vaccinations against influenza .1. Between October 1st and March
31st each year, the influenza vaccine shall be offered to residents in the facility, unless the vaccine is
medically contraindicated, or the resident has already been immunized .5. A resident's refusal of the
vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's
medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146168
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
FAQ · About this visit
Common questions about this visit
What happened during the March 2, 2023 survey of AHVA CARE OF WINFIELD?
This was a inspection survey of AHVA CARE OF WINFIELD on March 2, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AHVA CARE OF WINFIELD on March 2, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.