Deficiency Records for Winchester Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Winchester Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-04-19 | 2023-06-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-19 | 2023-06-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-04-19 | 2023-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-19 | 2023-06-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-12 | 2023-05-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-12 | 2023-05-26 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-04-12 | 2023-05-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-12 | 2023-05-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-04-12 | 2023-05-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-12 | 2023-05-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-12 | 2023-05-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-04-12 | 2023-05-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-12 | 2023-05-26 | 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 | 2023-04-12 | 2023-05-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-12 | 2023-05-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-12 | 2023-05-26 | N |
| 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 | 2023-04-12 | 2023-05-26 | 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 | 2023-04-12 | 2023-05-26 | N |
| 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 | 2023-04-12 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-12 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-12 | 2023-05-26 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-04-12 | 2023-05-26 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-04-12 | 2023-05-26 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-04-12 | 2023-05-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-12 | 2023-05-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-12 | 2023-05-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-12 | 2023-05-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-12 | 2023-05-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-12 | 2023-05-26 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-04-12 | 2023-05-26 | 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 | 2023-04-12 | 2023-05-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-12 | 2023-05-26 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-04-12 | 2023-05-26 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-12 | 2023-05-26 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-12 | 2023-05-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-28 | 2021-11-22 | 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 | 2021-09-28 | 2021-11-22 | N |
| Provide at least two remote exits on each floor or fire section of the building. | Fire Safety | 2021-09-28 | 2021-11-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-28 | 2021-11-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-09-28 | 2021-11-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-09-09 | 2021-10-14 | 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 | 2021-09-09 | 2021-10-14 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-09 | 2021-10-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-09 | 2021-10-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-09-09 | 2021-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-09 | 2021-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-09 | 2021-10-14 | 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 | 2021-09-09 | 2021-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-09 | 2021-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-09 | 2021-10-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-09 | 2021-10-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-09-09 | 2021-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-09 | 2021-10-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-09 | 2021-10-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-09-09 | 2021-10-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-09-09 | 2021-10-14 | N |
| 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 | 2021-09-09 | 2021-10-14 | N |
| Post nurse staffing information every day. | Health | 2021-09-09 | 2021-10-14 | 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 | 2021-09-09 | 2021-10-14 | N |
| Dispose of garbage and refuse properly. | Health | 2021-09-09 | 2021-10-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-09 | 2021-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-09 | 2021-10-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-09 | 2021-10-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-09 | 2021-10-14 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-09 | 2021-10-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-09 | 2021-10-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-29 | 2020-09-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-29 | 2020-09-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-29 | 2020-09-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-29 | 2020-09-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-09 | 2020-02-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-09 | 2020-02-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-01-09 | 2020-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-09 | 2020-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-09 | 2020-02-15 | 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 | 2020-01-09 | 2020-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-09 | 2020-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-09 | 2020-02-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-09 | 2020-02-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-09 | 2020-02-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-09 | 2020-02-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-09 | 2020-02-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-09 | 2020-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-09 | 2020-02-15 | N |
