Winchester Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Winchester Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF656Jun 13, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was non-ambulatory, whose plan of care indicated he/she required extensive assistance of two staff members for all transfers for safety, and had also been utilizing a Spryte lift (sit to stand transfer aid) for transfers which also required two members to be present during use, the Facility failed to ensure staff implemented and followed interventions identified in his/her Activities of Daily Living (ADL) plan of care related to transfers. […]

• Actual harm, isolatedF689Jun 13, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) who was non-ambulatory, who he/she required extensive assistance of two staff members for all transfers for safety, and had also been utilizing a Spryte lift for transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance during a transfer to help maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 3/09/23, during the day shift, Certified Nurse Aide (CNA) #1 transferred Resident #1 from his/her bed via a Spryte lift (sit to stand transfer aid) and onto the toilet without having another staff member present to assist her. […]

• No harm, potential for more than minimal, patternF759Feb 6, 2026

  Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of four nurses observed made six errors out of 25 opportunities resulting in a medication error rate of 24 %. Those errors impacted one Resident (#94) out of nine residents observed.Findings include:Review of the facility's policy titled Administering Medication, dated as revised May 2025, indicated the following:- Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. In a manor to prevent contamination or infection.11. […]

• No harm, potential for more than minimal, patternF761Nov 7, 2024

  Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice for four of four medication rooms. Specifically, nursing failed to ensure the codes to the medication rooms were not disclosed to unauthorized personal. Findings include: Review of the facility of policy, Medication Storage, dated 2/2023, indicated that it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. General Guidelines: a. […]

• No harm, potential for more than minimal, patternF656Nov 22, 2023

  Based on observations, record reviews and interviews, the facility 1) failed to implement skin integrity care plans for 3 Residents (#60, #73 and #74) and 2) failed to develop individualized care plans for 2 Residents (#202 and #75) out of a total sample of 24 Residents. Findings include: 1a. Resident #60 was admitted to the facility in March 2023 with diagnoses including stroke and dementia. Review of Resident #60's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 which indicated the Resident had severe cognitive impairment. The MDS also indicated the Resident required maximal assistance from staff to complete bed mobility tasks. […]