Winchester Rehabilitation and Nursing Center

Inspectors wroteBased 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.

Inspectors wroteBased on record reviews and interview the facility failed to ensure weights were obtained for one Resident (#12), resulting in the delay of identifying a weight loss, assessing the weight loss, and implementing interventions to prevent further weight loss, out of a total sample of 30 residents.

Inspectors wroteBased on observation, records reviewed, and interview, the facility failed to ensure residents were free of significant medication errors for four Residents (#94, #126, #86 and #51), out of a total sample of 30 residents. Specifically, 1. For Resident #94, during the medication pass observation, the facility failed to administer 9:00 A.M., medications in accordance with the physician's order, resulting in Resident #94 receiving medications two hours and 36 minutes after the scheduled time.2. For Resident #126, the facility failed to administer 9:00 A.M., medications in accordance with the physician's order.3. For Resident #86, the facility failed to administer 9:00 A.M., medications in accordance with the physician's order.4. For Resident #51, the facility failed to administer 9:00 A.M., medications in accordance with the physician's order.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, and interview, the facility failed to ensure Advance Directives (written documents that instruct health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#75), out of a total sample of 23 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement the plan of care for three Residents (#23, #13, #48) out of a total sample of 23 residents. Specifically: 1. For Resident #23, the facility failed to implement a left hand splint care plan. 2. For Resident #13, the facility failed to develop a pacemaker care plan. 3. For Resident #48, the facility failed to develop a risk for bleeding care plan. Findings Include: 1. Resident #23 was admitted to the facility in November 2016 with diagnoses including cerebral vascular disease, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side. Review of Resident #23's most recent Minimum Data Set (MDS) assessment, dated 8/14/24, indicated Resident #23 has severe cognitive deficits. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide services that met professional standards of quality for one Resident (#48) out of a total sample of 23 residents. Specifically, the facility failed to ensure nursing implemented a physician's order for weekly weights.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff adhered to professional standards of practice for the administration of enteral tube feeding (nutrition taken through a tube directly into the stomach) for one Resident (#259) out of a total sample of 23 residents. Specifically, the facility failed to consistently label and date the tube feeding bag.

Inspectors wroteBased on observation record review, and interview, the facility failed to ensure staff maintained an accurate medical record for two Residents (#23 and # 259) out of a sample of 23 residents. Specifically: 1. For Resident # 23, the facility failed to accurately document the wearing of a left hand splint . 2. For Resident #259, the facility failed to accurately document the start time for a tube feeding formula to be hung as ordered by the physician.

Inspectors wroteBased on interviews and records reviewed, for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated in July of 2022, the Facility failed to ensure it honored a request for copies of medical record information within two working days, when his/her Health Care Agent (HCA) requested copies of documentation from his/her medical record verbally and through email correspondence, but was not provided with copies in accordance with federal regulations.

Inspectors wroteBased on interviews and records reviewed, for three of three sampled residents (Resident #1, #2, and #3), the Facility failed to ensure that at the time of their discharges, that the residents, their legal representative(s) or Health Care Agents (HCA) were provided with Notice of Intent to discharge: that was complete, and included all pages of the notice, with necessary information to file an appeal, in accordance with federal regulations and per facility policy.

Inspectors wroteBased 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.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to complete a Quarterly MDS assessment timely for one Resident (#35), out of a total sample of 24 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility 1) failed to provide assistance with meals as needed for one Resident (#96) and #2) failed to provide scheduled showers for one Resident (#34) out of a total sample 24 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to identify a bruise on 1 Resident's (#96) wrist and document it on a skin assessment, out of a total sample 24 residents.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure medications, once opened were dated as required, on 3 of 4 sampled medication carts.

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain infection control standards. Specifically, the facility failed to 1.) initiate transmission based precautions for one Resident (#75) out of a total sample of 24 residents and 2.) failed to ensure infection control measures were implemented to prevent the spread of infection on 1 of 4 units.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of chronic kidney disease, required the administration of intravenous fluids, and had new orders for the placement of a Foley catheter (semi-flexible tube inserted into the bladder to help drain urine) to monitor fluid output due his/her history of urinary retention (inability to empty the bladder), the facility failed to ensure he/she received care and services that met professional standards of practice related to placement of a Foley, which included nursing documenation of placement of type and size of catheter, balloon size, and confirmation of urinary flow before inflating the balloon, per faciity policy.