Deficiency Records for Embassy of Winchester
Updated as of August 01, 2018
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? |
---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-20 | 2018-05-08 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-20 | 2018-05-08 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-20 | 2018-05-08 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-20 | 2018-05-08 | 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 ne | 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 | Y |
Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-08-25 | 2017-09-14 | Y |
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 | 2017-08-25 | 2017-09-14 | Y |
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 | 2017-08-25 | 2017-09-14 | Y |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-08-25 | 2017-09-14 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-08-10 | 2017-09-14 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2017-07-27 | 2017-09-14 | Y |
Maintain comfortable sound levels. | Health | 2017-07-27 | 2017-09-14 | Y |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-27 | 2017-09-14 | Y |
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-07-27 | 2017-09-14 | Y |
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-07-27 | 2017-09-14 | Y |
Provide care for each resident in a way that maintains or improves their quality of life. | Health | 2017-07-09 | 2017-09-14 | Y |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-09 | 2017-09-14 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-06-06 | 2017-09-14 | Y |
Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-06-06 | 2017-09-14 | Y |
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 | 2017-06-06 | 2017-09-14 | Y |
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 | 2017-06-06 | 2017-09-14 | Y |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-06 | 2017-09-14 | Y |
Give the resident's representative the ability to exercise the resident's rights. | Health | 2017-04-03 | 2017-04-14 | Y |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-03 | 2017-04-14 | Y |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-03 | 2017-04-14 | Y |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-02-16 | 2017-03-08 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-02-03 | 2017-03-08 | Y |
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 |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-12-06 | 2016-12-18 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-06 | 2016-12-18 | Y |
Store, cook, and serve food in a safe and clean way. | Health | 2016-12-06 | 2016-12-18 | Y |
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 |
Have a program that investigates, controls and keeps infection from spreading. | 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 | Y |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-10-20 | 2016-12-18 | Y |
Reasonably accommodate the needs and preferences of each resident. | Health | 2016-08-24 | 2016-09-13 | Y |
Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-08-24 | 2016-09-13 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-08-24 | 2016-09-13 | Y |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-08-24 | 2016-09-13 | Y |
Provide special eating equipment and utensils for each resident who needs them. | Health | 2016-08-24 | 2016-09-13 | Y |
Store, cook, and serve food in a safe and clean way. | Health | 2016-08-24 | 2016-09-13 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-05-20 | 2016-06-03 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-05-20 | 2016-06-03 | Y |
Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-03-28 | 2016-04-29 | Y |
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-03-28 | 2016-04-29 | Y |
Provide housekeeping and maintenance services. | Health | 2016-03-28 | 2016-04-29 | Y |
Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-03-28 | 2016-04-29 | Y |
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel. | Health | 2015-12-08 | 2015-12-16 | Y |
Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-07-21 | 2015-08-18 | N |
Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-07-21 | 2015-08-18 | N |
Exits that are free from obstructions and can be used at all times. | Fire Safety | 2015-07-21 | 2015-08-18 | N |
Proper medical gas storage and administration areas. | Fire Safety | 2015-07-21 | 2015-08-18 | N |
Properly installed electrical wiring and equipment. | Fire Safety | 2015-07-21 | 2015-08-18 | N |
Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2015-07-22 | 2015-08-18 | 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 | 2015-07-22 | 2015-08-18 | 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 | 2015-07-22 | 2015-08-18 | N |
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2015-07-22 | 2015-08-18 | N |
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2015-07-22 | 2015-08-18 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2015-07-22 | 2015-08-18 | N |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2015-07-22 | 2015-08-18 | N |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-07-22 | 2015-08-18 | N |
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-07-22 | 2015-08-18 | N |
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2015-07-22 | 2015-08-18 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-07-22 | 2015-08-18 | N |
Ensure residents maintain acceptable nutritional status. | Health | 2015-07-22 | 2015-08-18 | N |