A list of the most recent deficiencies for Winchester Terrace. 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? |
|---|---|---|---|---|
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-19 | 2024-02-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-13 | 2023-05-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-13 | 2023-05-26 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-04-13 | 2023-05-26 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-04-13 | 2023-05-26 | 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 | 2023-04-13 | 2023-05-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-13 | 2023-05-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-13 | 2023-05-26 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-04-13 | 2023-05-26 | 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 | 2023-04-13 | 2023-05-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-13 | 2023-05-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-13 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-13 | 2023-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-13 | 2023-05-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-13 | 2023-05-26 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-27 | 2023-03-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-11 | 2023-02-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-11 | 2023-02-11 | Y |
| Post nurse staffing information every day. | Health | 2023-01-11 | 2023-02-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-12 | 2023-02-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-12 | 2023-02-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-12 | 2023-02-11 | 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 | 2022-12-12 | 2023-02-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-12 | 2023-02-11 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-01-20 | 2022-03-03 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-01-20 | 2022-03-03 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-01-20 | 2022-03-03 | Y |
| 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 | 2022-01-20 | 2022-03-03 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-20 | 2022-03-03 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-01-20 | 2022-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-09 | 2022-01-07 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-10-28 | 2022-01-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-28 | 2022-01-07 | Y |
| Post nurse staffing information every day. | Health | 2021-10-28 | 2021-11-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-19 | 2021-09-17 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-05 | 2020-01-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-05 | 2020-01-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-12-05 | 2020-01-21 | 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 | 2019-12-05 | 2020-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-05 | 2020-01-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-05 | 2020-01-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-05 | 2020-01-21 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-05 | 2020-01-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-12-05 | 2020-01-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-05 | 2020-01-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-05 | 2020-01-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-05 | 2020-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-05 | 2020-01-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-12-05 | 2020-01-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-12-05 | 2020-01-21 | 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 | 2019-12-05 | 2020-01-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-05 | 2020-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-05 | 2020-01-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-05 | 2020-01-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-12-05 | 2020-01-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-05 | 2020-01-21 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2018-11-07 | 2018-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-07 | 2018-12-18 | 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 | 2018-11-05 | 2018-12-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-05 | 2018-12-18 | N |
