Deficiency Records for Embassy of Winchester
Updated as of July 01, 2023
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? |
---|---|---|---|---|
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 |
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 |
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 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 |
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 |
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 |