Deficiency Records for Embassy of Winchester
Updated as of September 01, 2021
This is not the most recent data for Embassy of Winchester. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-19 | 2021-07-20 | 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 | 2021-07-19 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-06-22 | 2021-07-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-13 | 2021-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-13 | 2021-06-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-13 | 2021-06-08 | 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 | 2021-06-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-30 | 2021-05-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-11 | 2021-03-08 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-02-11 | 2021-03-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-29 | 2021-03-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-01-29 | 2021-03-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-01-08 | 2021-03-08 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-01-08 | 2021-03-08 | Y |
| 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 | 2020-10-29 | 2020-12-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-29 | 2020-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-29 | 2020-12-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-29 | 2020-12-01 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-10-29 | 2020-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-29 | 2020-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-05-27 | 2020-07-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-07-20 | 2020-07-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-07-06 | 2020-07-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-07-06 | 2020-07-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-07-06 | 2020-07-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-06 | 2020-07-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-07-06 | 2020-07-24 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-06-16 | 2020-07-24 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-06-16 | 2020-07-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-16 | 2020-07-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-05-27 | 2020-07-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-14 | 2020-01-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-14 | 2020-01-20 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-01-14 | 2020-01-20 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-11-25 | 2020-01-20 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-11-25 | 2020-01-20 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-11-25 | 2020-01-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-25 | 2020-01-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-25 | 2020-01-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-09 | 2020-01-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2019-10-09 | 2020-01-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-24 | 2019-10-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-19 | 2019-07-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-19 | 2019-07-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-19 | 2019-07-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-07-19 | 2019-07-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-25 | 2019-07-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-25 | 2019-07-24 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-25 | 2019-07-24 | Y |
| 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 | 2019-06-25 | 2019-07-24 | Y |
| 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 other general requirements that are deficient. | 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 |
| 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 |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-01-23 | 2019-02-13 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-25 | 2018-11-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-11-12 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-10 | 2018-02-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-01-11 | 2018-02-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-01-11 | 2018-02-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-01-11 | 2018-02-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-01-11 | 2018-02-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-01-11 | 2018-02-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-01-11 | 2018-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-11 | 2018-02-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-01-11 | 2018-02-02 | 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 | 2018-01-11 | 2018-02-02 | 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 | 2018-01-11 | 2018-02-02 | 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 | 2018-01-11 | 2018-02-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-01-11 | 2018-02-02 | 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 | 2018-01-11 | 2018-02-02 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-01-11 | 2018-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-11 | 2018-02-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-01-11 | 2018-02-02 | N |
| Approved construction type or materials. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| Proper construction of ducts through walls designed to prevent smoke passage. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-10-20 | 2016-12-18 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-10-20 | 2016-12-18 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-10-20 | 2016-12-18 | N |
| 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. | Health | 2016-10-20 | 2016-12-18 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-10-20 | 2016-12-18 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-10-20 | 2016-12-18 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-10-20 | 2016-12-18 | N |
