A list of the most recent deficiencies for Embassy of Winchester. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-16 | 2023-12-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-11-16 | 2023-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-16 | 2023-12-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-16 | 2023-12-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-16 | 2023-12-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-16 | 2023-12-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-11-16 | 2023-12-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-11-16 | 2023-12-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-11-16 | 2023-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-28 | N |
| Keep all essential equipment working safely. | Health | 2023-11-16 | 2023-12-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | 2023-12-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-16 | 2023-12-28 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-14 | 2023-12-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-16 | 2023-12-13 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-20 | 2023-10-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-03 | 2023-08-22 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-08-03 | 2023-08-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-18 | 2022-11-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-05 | 2021-12-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-05 | 2021-12-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-11-05 | 2021-12-10 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-11-05 | 2021-12-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-05 | 2021-12-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-11-05 | 2021-12-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-05 | 2021-12-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-05 | 2021-12-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-11-05 | 2021-12-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-05 | 2021-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-05 | 2021-12-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-11-05 | 2021-12-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-05 | 2021-12-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-05 | 2021-12-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-05 | 2021-12-10 | N |
| 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. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide or obtain dental services for each resident. | Health | 2021-11-05 | 2021-12-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-05 | 2021-12-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-05 | 2021-12-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-05 | 2021-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-09 | 2021-12-10 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-27 | 2021-12-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-09-15 | 2021-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-12 | 2021-09-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-12 | 2021-09-16 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-08-12 | 2021-09-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-12 | 2021-09-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-19 | 2021-09-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-22 | 2021-09-16 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-06-22 | 2021-09-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-13 | 2021-09-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-13 | 2021-09-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-13 | 2021-09-16 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-05-13 | 2021-09-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-30 | 2021-09-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-21 | 2019-05-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-21 | 2019-05-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-21 | 2019-05-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-21 | 2019-05-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-03-21 | 2019-05-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-21 | 2019-05-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-21 | 2019-05-04 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-03-21 | 2019-05-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-03-21 | 2019-05-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-21 | 2019-05-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-21 | 2019-05-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-21 | 2019-05-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-21 | 2019-05-04 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-18 | 2019-05-04 | N |
