Cycle 1
Health 2024-06-05 · Fire 2024-06-05
5 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Winfield, KS
Cumbernauld Village
4-star overall rating with 2-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
716 Tweed Street, Winfield, KS
(620) 221-4141
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
42
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2022-12-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.56
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.07
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.12
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.21
CMS adjusted RN staffing hours
Adjusted total hours
5.64
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.89% |
8.2%
0.7 pts better
|
Numerator 8 · Denominator 90 |
| Staff flu vaccination coverage | 11.82% |
42%
30.2 pts worse
|
Numerator 13 · Denominator 110 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.2
0.9 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.1% |
95.5%
9.4 pts worse
|
95.5%
9.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
4.4%
3.7 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.4% |
5.6%
3.8 pts worse
|
11.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 6.2% · Q3 15.2% · Q4 5.9% · 4Q avg 9.4% |
| Percentage of long-stay residents who lose too much weight | 12.1% |
5.0%
7.1 pts worse
|
5.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.2% · Q3 6.2% · Q4 12.5% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
23.2%
3.2 pts better
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 17.6% · Q3 17.6% · Q4 18.8% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
19.8%
12.5 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 9.4% · Q3 7.1% · Q4 4.0% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.5% |
18.4%
4.9 pts better
|
16.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
18.8%
7.2 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 21.4% · Q3 21.4% · Q4 26.9% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
3.1%
1.5 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
23.2%
0.3 pts better
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 13.5% · Q3 21.7% · Q4 29.4% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.6%
0.5 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.0% · Q3 2.7% · Q4 4.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
75.6%
18.7 pts better
|
81.7%
12.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 94.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.1% |
2.2%
3.9 pts worse
|
1.6%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-17 · Fire 2022-11-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health · Fire
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-22
F · Potential for more than minimal harm
2024-06-05
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-08-22
F · Potential for more than minimal harm
2024-06-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-22
F · Potential for more than minimal harm
2024-06-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-22
F · Potential for more than minimal harm
2024-06-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-22
F · Potential for more than minimal harm
2022-11-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-21
F · Potential for more than minimal harm
2022-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-13
F · Potential for more than minimal harm
2022-11-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-10
F · Potential for more than minimal harm
2024-06-05
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-10
L · Immediate jeopardy
2023-03-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-11
D · Potential for more than minimal harm
2022-11-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-05
D · Potential for more than minimal harm
2022-11-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-05
Penalties and ownership
What sits behind the stars
Ownership
Cumbernauld Village, Inc.
5% Or Greater Direct Ownership Interest · Organization
Andreas, David
Corporate Director · Individual
Blake, Bruce
Corporate Officer · Individual
Cumbernauld Village, Inc.
Operational/Managerial Control · Organization
Griggs, Sarah
Operational/Managerial Control · Individual
Griggs, Sarah
Corporate Director · Individual
Long, Jill
Corporate Officer · Individual
Mcneish, Marilyn
Corporate Officer · Individual
Steffen, Rodger
Corporate Director · Individual
Taylor, Sharon
Corporate Officer · Individual
Teubner, Doug
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Kansas Veterans Home
Winfield, KS
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Winfield Senior Living Community
Winfield, KS
2-star overall rating with 2-star inspections with $18,896 in total fines with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Winfield Rest Haven Ii, LLC
Winfield, KS
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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