Embassy of Winchester

Inspectors wroteBased 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). [...]

Inspectors wroteBased on observations, review of physician orders, staff interview, and policy review, the facility failed to properly store and date food items in the freezer. This had the potential to affect all 90 residents who receive food from the kitchen. Residents #28 and #56 receive no food by mouth. The facility census was 92.

Inspectors wroteBased on observations, interview, medical record review, and review of facility policy, the facility failed to ensure the call light was in reach at all times for one resident. This affected one (Resident #21) of two residents reviewed for environment. The facility census was 92 residents.

Inspectors wroteBased on medical record review, financial record review, staff interview, and policy review, the facility failed to ensure resident funds were handled appropriately and failed to prevent the mixing of resident's funds with facility funds. This affected two (Residents #25 and #89) of five resident financial records reviewed. The census was 92.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure a resident with a suprapubic catheter was provided preventative care to prevent potential complications of infection and possible dislodgement. This affected one (Resident #14) of one resident reviewed for urinary catheters. The facility census was 92 residents.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to change the oxygen tubing per physician order for one resident. This affected one (Resident #3) of two resident reviewed for respiratory care. The facility census was 92 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to administer medications in accordance with the parameters ordered by the physician. This affected one (Resident #34) of five residents reviewed for unnecessary medications. The facility census was 92.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the resident's room had outlet covers to ensure the electrical wiring was covered. This affected one (#11) of 24 residents reviewed for physical environment. The facility census was 92.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the safety of Resident #71 during a Hoyer lift transfer. This had the potential to affect 14 residents who the facility identified as requiring the assistance of a Hoyer lift for transfers. The facility census was 87.

Inspectors wroteBased on observation and interview the facility failed to perform hand hygiene during incontinence care for Resident #71. This had the potential to affect 20 residents who the facility identified as requiring assistance with incontinence care. The facility census was 87.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to prepare and handle food in a sanitary manner. This affected 85 residents in the facility who receive food from the kitchen. The facility identified two residents who were nothing-by mouth (NPO). The facility census was 87.

Inspectors wroteBased on medical record review, self-reported incident (SRI) investigation review, staff interview, and review of the facility's abuse policy and procedure, this facility failed to ensure an allegation of resident-to-resident sexual abuse was submitted to the appropriate state agency as required. This affected two (Resident #410 and #510) of the three residents reviewed for sexual abuse. The facility census was 87.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review the facility failed to perform hand hygiene during incontinence care. This affected one (Resident #374) of one resident observed during incontinence care . The census was 87.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a clean, safe, and comfortable living environment for residents. This had the potential to affect all residents in the facility. The facility census was 94.

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge Minimum Data Set (MDS) 3.0 assessments were completed accurately and a correction was submitted timely to reflect Resident #90's disposition. This affected one resident (#90) out of four residents reviewed for MDS assessments. The facility census was 94.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pressure reducing devices were free from soil. This affected one (Resident #33) out of three residents reviewed for pressure reducing measures. The facility census was 94.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure name badges were worn at all times by facility staff. This affected all 93 residents at the facility. Facility census was 93.

Inspectors wroteBased on interviews, observation and policy review, the facility failed to ensure scheduled activities were completed as well as ensuring evening activities were scheduled. This affected 92 residents (except for Resident #233) who attend/participate in activities. The facility census was 93.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to complete staff performance evaluations as required. This had the potential to affect 88 of 88 residents. Findings Include: Review of Certified Nursing Assistant (CNA) #165 and CNA #179 personnel records found they did not have a completed 90 day performance evaluation completed. Interview with Visiting Administrator #600 on 12/04/24 at 10:30 A.M. confirmed they have no evidence to support the above staff had performance evaluations completed as required.

Inspectors wroteBased on observations , and staff interviews the facility failed to ensure the steam warmer and two compartment sink was maintained in a safe and operating condition . This had the potential to affect 85 residents. The census was 88.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for one resident (Resident #189) who had a feeding tube in place. The facility also failed to follow infection control procedures during wound care for two residents (Residents #81 and #300) and did not follow infection control procedures during catheter care for one resident (Resident #10). The deficient practices affected four residents (#10, #81, #189, #300) of four reviewed for infection control. The facility census was 88. Findings Include: 1. [...]

Inspectors wroteBased on interviews, and resident council meeting notes the facility failed to document in writing its responses and rationale to resident council grievances and recommendations. This had the potential to affect eight (#1, #9, #24, #14, #42, #51, #58 and # 66) residents who attend the meetings monthly. The census was 88.

Inspectors wroteBased on medical record review, facility record review, staff interview, and facility policy review, the facility failed to provide the opportunity to view or receive resident medical records in a timely manner. This affected one (Resident #65) of one resident reviewed for medical record release. The census was 88. Findings Include: Resident #65 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to notify the physician after a significant weight change occurred for Resident #66. This affected one (Resident #66) of five residents reviewed for nutrition. The facility census was 88.

Inspectors wroteBased on record review, staff interview, resident interview, and policy review, the facility failed to complete a timely and thorough grievance investigation and resolution for resident #9's grievances. This affected one (Resident #9) of two residents reviewed for grievance handling. The facility census was 88.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to develop a comprehensive plan of care for residents. This affected three (#10,#18, and #69) of 24 sampled residents. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, diabetes mellitus, congestive heart failure (CHF), depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. [...]

Inspectors wroteBased on observations, interviews and policy and procedure review the facility failed to invite residents' family and or resident representative to a residents' Care Conference. This had the potential to affect two residents (#50 and #70) . The census was 88 .

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident (#10), who was dependent on staff received routine nail care. This affected one resident (#10) of four resident reviewed for activities of daily living (ADL). The facility census was 88.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to follow physician orders for as needed pain medication administration. This affected one (Resident #65) of three residents reviewed for opioid use. Also, the facility failed to follow wound care orders. This affected one (Resident #70) of three residents reviewed for wound care. The census was 88. Findings Include: 1. Resident #65 was admitted to the facility on [DATE]. Her diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. [...]

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure off-loading skin interventions were in place as physician ordered for one resident. This affected one resident (#10) of two residents reviewed for pressure ulcers. The facility census was 88. Findings Include: Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to COPD, severe protein calorie malnutrition, diabetes mellitus, CHF, depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure appropriate enteral feeding services were provided Resident #189. This affected one (Resident #189) of one resident reviewed for tube feeding services. The facility census was 88.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to ensure provision of appropriate equipment was at the bedside for immediate access for two residents (#9 and #69) and failed to ensure one resident's (#10) nasal cannula oxygen delivery equipment was dated. This affected three residents ( Resident #9,#10 and #69) of three residents reviewed for respiratory care. The facility census was 88. Findings Include: 1. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to have all dialysis communication and records were in the facility to ensure full care could be provided. This affected one (Resident #65) of one resident reviewed for dialysis. The census was 88. Findings Include: Resident #65 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. other psychoactive substance abuse, cognitive communication deficit, lack of coordination, dysphagia, congestive heart failure, atherosclerotic heart disease, pure hypercholesterolemia, low back pain, neuropathy, major depressive disorder, hyperlipidemia, adult failure to thrive, esophagitis, anxiety disorder, and allergic rhinitis. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to properly monitor residents psychotropic medications to ensure the need/appropriate dose of psychotropic medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 88.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure adequate monitoring was completed for a medication as ordered for Resident #9. This affected one (Resident #9) of six residents reviewed for unnecessary medications. The facility census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to properly monitor resident behaviors to ensure the need/appropriate dose of psychotropic medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 88.

Inspectors wroteBased on record review, staff interview, resident interview, and policy review, the facility failed to ensure timely collection of a urine sample for a urinary tract infection (UTI) as ordered for Resident #81. This affected one (Resident #81) out of one resident reviewed for labs. The facility census was 88.

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident (#18) oral assessments were accurate and dental services were arranged to address the resident's poor dental status. This affected one resident (Resident #18) of one resident reviewed for dental. The facility census was 88. Findings Include: Review of the medical record for Resident #18 revealed an initial admission date of 08/07/24 with the most recent admission of 10/11/24 with the diagnoses including but not limited to diabetes mellitus, neuromuscular dysfunction of bladder, fibromyalgia, arthritis, major depressive disorder with psychotic features, obstructive sleep apnea, gastro-esophageal reflux disease, paraplegia, pain, constipation, osteoarthritis, dysphagia and urinary tract infection (UTI). [...]

Inspectors wroteBased on record review,staff interview, and facility policy review, the facility failed to follow their antibiotic stewardship processes for Residents #81 and #43. This affected two (Resident's #81 and #43) out of three residents reviewed for antibiotic use. The facility census was 88.

Inspectors wroteBased on medical record review, review of immunization records, staff interview, and facility policy review, the facility failed to administer the influenza vaccine to one resident (Resident #20) and the facility failed to administer the pneumococcal vaccine to one resident (Resident #6) after the residents consented to receive the vaccinations. The deficient practice affected two residents (Residents #6 and #20) of five reviewed for immunizations. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #20 revealed an initial admission date on 01/18/24 and a readmission date on 03/08/24. Medical diagnoses included Type II Diabetes Mellitus without complications, metabolic encephalopathy, vascular dementia, essential hypertension, and cognitive communication deficit. [...]

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility did not keep an accurate record of skin wound assessments in the medical record for one (Resident #101) out of three residents with skin wounds. The facility census was 87.

Inspectors wroteBased 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. There was no evidence of adequate and necessary interventions in place prior to the development of the ulcer. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep clean drying dishware in a clean dry location and not exposed to dust or other contamination. This had the potential to affect 87 out of 88 residents who receive beverages from the facility. The facility census was 88.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to export resident assessments in a timely manner. This affected 16 (Residents #5, #16, #25, #35, #38, #39, #40, #44, #48, #50, #51, #52, #56, #67, #74, and #83) of 19 resident assessments reviewed. The census was 88. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Her diagnoses were dementia, anemia, type II diabetes, depression, COPD, schizoaffective disorder, hyperlipidemia, hypothyroidism, dysphagia, schizophrenia, hypokalemia, aphasia, osteoarthritis, hypertension, cognitive communication deficit, altered mental status, and psychosis. Review of her Minimum Data Set (MDS) assessment, dated 07/06/23, revealed she had a severe cognitive impairment. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving to residents on a pureed diet and required surveyor intervention for safety. This had the potential to affect nine residents (Residents #7, #49, #39, #5, #75, #4, #81, #64, and #52) who were on a prescribed pureed diet. The facility census was 88. Findings Include: 1. Observation on 11/15/23 at 10:48 A.M. with [NAME] #117 revealed the cook was preparing pureed Italian blend vegetables. [NAME] #117 confirmed the menu for lunch was Italian blend mixed vegetables and barbeque chicken. The recipes were observed to the left of [NAME] #117 during preparation. Vegetables in the Italian vegetable mix include carrots, green beans, cauliflower, and broccoli. Dietary Manager (DM) #178 was present for observation. [...]

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to appropriately confirm one resident's (Resident #71's) code status. This affected one resident (Resident #71) of one resident reviewed for advanced directives. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on [DATE]. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the Durable Power of Attorney for Management of Property and Personal Affairs dated [DATE] revealed Resident #71 named his wife to be Power of Attorney (POA) for finances only. There was not a POA for healthcare decisions named for Resident #71. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to accurately assess one resident's (Resident #71) cognition. This affected one resident (Resident #71) of one reviewed for appropriate cognitive status. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to develop and implement a comprehensive plan of care for three residents (#33, #53, #61) in the area of contractures and antipsychotic medication use. This affected one (Resident #61) of one resident reviewed for contractures and two (Resident #33 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. [...]

Inspectors wroteBased on medical record review, staff interviews, and facility policy review, the facility failed to revise a comprehensive care plan to specifically address one resident's (Resident #71) cognitive status changes and whether or not a legal resident representative was needed for healthcare decision making. This affected one resident (Resident #71) of 20 residents reviewed for care plans. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the Durable Power of Attorney for Management of Property and Personal Affairs dated 01/24/22 revealed Resident #71 named his wife to be Power of Attorney (POA) for finances only. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident's (Resident #239) vital signs were checked upon returning from dialysis treatments. This affected one resident (Resident #239) of one reviewed for dialysis. The facility census was 88. Findings Include: Review of the medical record for Resident #239 revealed and initial admission date on 10/24/23 and a readmission date on 11/03/23. Medical diagnoses included cognitive deficit deficit, end stage renal disease, and acute kidney failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #239 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #239's function level varied from supervision with eating to total dependence with personal hygiene. [...]

Inspectors wroteBased on medical record review, staff interview, review of pharmacy recommendations, and facility policy review, the facility failed to timely address a pharmacy recommendation for one resident (Resident #33) and failed to provide a rationale for declining a Gradual Dose Reduction (GDR) for two residents (Residents #28 and #33). This affected two residents (Residents #28 and #33) of five reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure parameters for when the physician should be notified were provided for one resident's (Resident #33) insulin orders. This affected one resident (Resident #33) of five reviewed for unnecessary medications. The facility census was 88. Findings Include: Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with neuropathy and chronic kidney disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had the following insulin orders: [...]

Inspectors wroteBased on record review and interview, the facility failed to identify target behaviors for the use of antipsychotic medications for three residents (#28, #33, #53) and failed to monitor for side effects of antipsychotic medication use for one resident (#33). This affected three of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain laboratory tests for residents as physician ordered. This affected two (Resident #28 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to maintain one resident's (Resident #239) wheelchair in proper working order. This affected one of 22 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #239 revealed an initial admission date of 10/24/23 with the latest readmission of 11/03/23 with diagnoses including cognitive communication deficit, retention of urine, end stage renal disease, dependence on hemodialysis and acute kidney failure. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive deficit. On 11/13/23 at 4:22 P.M., interview with Resident #239 revealed she had two different foot pedals to her wheelchair and the left foot pedal would not latch causing her legs spread when moved. [...]

Inspectors wroteBased on medical record review, resident and staff interview, observation, policy review, and review of a Centers for Medicare and Medicaid Services (CMS) memo, the facility failed to ensure activities were provided to meet the needs of the residents. This affected three (#38, #40, and #86) of three residents reviewed for activities. The census was 87.