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Deficiency Records for Winchester Health and Rehabilitation

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.

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
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
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
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
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 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
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-09-09 2021-10-14 N
Dispose of garbage and refuse properly. Health 2021-09-09 2021-10-14 N
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 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
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

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