Winchester Terrace

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 18, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, staff interview, review of the facility incident and accident log, review of hospital records, review of staff statements, and review of facility policy, the facility failed to ensure staff operated Hoyer lifts in a safe manner to prevent falls. This resulted in Actual Harm on 08/20/25 at approximately 6:30 A.M. when Certified Nursing Assistant (CNA) #236 and Registered Nurse (RN) #252 transferred Resident #03 out of bed with the use of a Hoyer lift and did not ensure the transfer sling straps were secured. […]

• Actual harm, isolatedF689Nov 6, 2024

  Based on observation, medical record review, Self-Reported Incident (SRI) review, review of hospital records, facility investigation review, personnel file review, staff interview, and review of facility policy, the facility failed to ensure Resident #10 was transferred in a safe manner and as per the resident's assessed/planned needs to prevent an avoidable accident resulting in major injury. Actual harm occurred on 09/08/24 when Certified Nursing Assistant (CNA) #400 attempted to transfer Resident #10, who required the use of a mechanical lift for transfers, out of bed without an additional staff assisting and using the resident's walker. […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2026

  Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 56 residents who consumed food from the kitchen. The facility census was 56.Findings include:Observation on 06/29/26 at 9:15 A.M. revealed the dish room revealed multiple broken and chipped tiles. On the left side, the baseboard was coming away from the wall exposing a large area of wall beneath. Additionally, tiles were coming up under the dishwasher, dishwashing area, and around the drain causing water to pool. There were broken tiles underneath the three-compartment sink and the food preparation sink. Underneath the food preparation sink, the tiles were cracked around the drain and there was standing water. […]

• No harm, potential for more than minimal, widespreadF925Jun 30, 2026

  Based on observation, review of pest control visit documents, staff interview, and review of a facility policy, the facility failed to ensure an effective pest control program was provided to eradicate pests in the facility. This had the potential to affect all 56 residents residing in the facility. The census was 56.Findings include:Observation on 06/29/26 at 9:15 A.M. revealed there were numerous flying insects (gnats) in the kitchen, with the highest concentration in the dish room. There were floor tiles coming up under the dishwasher, dishwashing area, and around the drain causing water to pool. Noted underneath the food preparation sink the floor tiles were cracked around the drain and there was standing water. Interview on 06/29/26 at 9:15 A.M. […]

• No harm, potential for more than minimal, widespreadF921Sep 18, 2025

  Based on observation, staff interview, review of electronic mail (e-mail) correspondence, and review of the facility policy, the facility failed to maintain a clean, safe and sanitary environment. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.Findings include:Observation on 09/17/25 at 3:03 P.M. of the courtyard entrance, located near the front doors, revealed a laminate type flooring that was raised and buckled. The flooring was not secured to the floor and could be lifted off of the floor. Further observation revealed spaces between the flooring slats. Observation on 09/17/25 at 3:10 P.M. of the Malabar Lane Hall revealed large areas of discoloration/stains on the carpeting throughout the hallway. […]