Deficiency Records for Embassy of Winchester
Updated as of September 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? |
|---|---|---|---|---|
| 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 | 2018-07-05 | 2018-08-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-07-05 | 2018-08-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-05 | 2018-08-10 | Y |
| 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 |
