Winslow House Care Center

In the surveyor’s words

From the most serious findings on record at Winslow House Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 24, 2023

  Based on clinical record review, observation, staff and resident interviews and policy review, the facility failed to ensure staff protected and prevented potential resident to resident abuse for 2 of 3 residents reviewed (Resident #1 and #2), when Resident #2 attempted to suffocate Resident #1 with a blanket and pillow while she lay in bed sleeping. Resident #2 had a known history of resident to resident altercations and the facility failed to evaluate the effectiveness of interventions implemented to prevent harm to other residents. A serious adverse outcome was likely to occur if the staff had not intervened and stopped Resident #2 from applying pressure with the pillow over another resident's face. The resident could have suffered asphyxia, when the body doesn't get enough oxygen. […]

• Immediate jeopardy, isolatedF689Apr 24, 2023

  Based on clinical record review, observation, and staff interviews the facility failed to provide adequate supervision to prevent a potential resident to resident abuse to occur for a resident diagnosed with Dementia and identified to exhibit verbal and physical behaviors to others(Resident #2) for 2 out of 3 residents reviewed (Residents #1 and #2). Resident #2 attempted to suffocate Resident #1 with a blanket and pillow while she lay in bed sleeping. Resident #2 had a known history of resident to resident altercations and the facility failed to evaluate the effectiveness of interventions implemented to prevent harm to other residents. […]

• Actual harm, isolatedF689Jan 28, 2026

  Based on observation, clinical record review, facility policy and staff and resident interviews the facility failed to appropriately transfer a resident from the bed to chair with the use of a mechanical lift in order to prevent a fall with injury for one of three residents reviewed (Resident #4). The full body lift tipped during Resident #4's transfer, and the resident sustained a bruise and skin tear. The facility reported a census of 47 residents.The facility corrected the deficient practice through past-noncompliance through the following actions: *Staff education completed 12/26/25 and 12/29/25 regarding full body lift safety *Removal of the full body mechanical lift pending inspection*Completion of weekly patient lift inspectionFindings include:1.The MDS (Minimum Data Set) dated… […]

• Actual harm, isolatedF689Mar 7, 2024

  Based on clinical record review, interview, and facility investigation review, the facility failed to maintain an environment as free as possible from hazards when wheelchair foot pedals had been omitted prior to transfer resulting in fracture injury for 1 of 3 residents reviewed for accidents (Resident #200). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed Resident #200 required a manual wheelchair for mobility, had lower extremity impairment, and dependent on staff for all transfers. Diagnoses included Heart Failure, Peripheral Vascular Disease (PVD), and polyneuropathy. Resident rated pain at 5 out of 10 that occasionally interfered with sleep and daily activities. […]

• No harm, potential for more than minimal, patternF865Jan 28, 2026

  Based on staff interview and Centers for Medicare and Medicaid Services (CMS) 2567 review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to identify previously identified deficiencies, resulting in a repeated deficiency cited on the current survey and cited in the previous survey. The facility reported a census of 47 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) 2567 form dated 9/25/2025, reflected a deficiency identified for staff failure to use Enhanced Barrier Precautions while doing resident cares for those identified as a risk. […]