Embassy of Winchester

In the surveyor’s words

From the most serious findings on record at Embassy of Winchester, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Nov 5, 2021

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), review of facility policy and procedures, review of the facility floor plan, observations, staff interviews and record reviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. […]

• Immediate jeopardy, isolatedF684Jun 22, 2026

  Based on record review, resident and staff interviews, review of the Emergency Medical Services (EMS) run report, review of the death certificate, policy review, and review of the National Institutes of Health guidance, the facility failed to ensure Resident #96 was monitored for acute respiratory failure when oxygen saturations went to 65 percent and failed to appropriately assess a resident's change in condition. This resulted in Immediate Jeopardy and the serious life-threatening harm and death on [DATE] when Resident #96 exhibited a change in condition. Resident #96 was assessed with a low oxygen level (O2) of 65 percent and exhibited shortness of breath (SOB). At 1:34 A.M., Resident #96's 02 saturation was 91 percent with oxygen at four liters per minute (LPM). […]

• Immediate jeopardy, isolatedF600Nov 5, 2021

  Based on closed record review, review of an emergency medical service (EMS) run report, facility Post-Mortem policy and procedure review, facility Abuse/Neglect policy and procedure review, staff interview, interview with Emergency Medical Service/Paramedic #545 and #546 and interview with Contracted Funeral Home Transport #543, the facility failed to provide adequate and immediate post-mortem care to Resident #128 following the resident's death in the facility on [DATE] resulting in neglect of the resident's corpse. This resulted in Immediate Jeopardy, when on [DATE] at approximately 8:00 A.M. Resident #128's body was released to the funeral home without evidence of post-mortem care having been provided by facility staff. […]

• Immediate jeopardy, isolatedF678Nov 5, 2021

  Based on observation, closed record review, review of an Emergency Medical Service (EMS) squad run report, review of a staff witness statement, review of the facility emergency response policy, staff interview and interview with Paramedic (EMT) #545 and EMT #546, the facility failed to initiate timely and adequate Cardio-pulmonary Resuscitation (CPR) for Resident #128 who was a full-code and required CPR after being found unresponsive and without vital signs. This resulted in Immediate Jeopardy on [DATE] at approximately 3:21 A.M. when Resident #128 was observed unresponsive. The facility failed to ensure EMS had timely access to the facility and failed to provide CPR timely for the resident. […]

• Actual harm, isolatedF686Nov 16, 2023

  Based on observation, medical record review, facility policy and procedure review and interview, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #79. Actual harm occurred on 08/10/23 when Resident #79, who was moderately cognitively impaired, at risk for pressure ulcer development and required extensive assistance from staff for bed mobility, developed an unstageable (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) pressure ulcer to the right heel. […]