Winchester Terrace

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, review of an medication error investigation, and staff interview, the facility failed to ensure medications were administered to residents as ordered, resulting in a significant medication error. This affected one (#90) of three residents reviewed for medication errors. The census was 56.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure mechanical lifts were operated safely. This affected one (#21) of one resident reviewed for mechanical lift transfers. The facility census was 53.

Inspectors wroteTHE 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. During the transfer, the Hoyer lift became stuck and staff forcefully pulled the Hoyer lift, causing the transfer sling strap to disconnect from the lift and Resident #03 fell to the floor. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. This improper transfer resulted in Resident #10 falling backwards onto the bed, striking her right elbow on the metal bed frame causing pain, a decrease in function of the resident's arm, swelling, redness, warmth and scattered bruising. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review the facility failed to maintain infection control measures during incontinence care for a resident. This deficient practice affected one resident (Resident #13) of three residents reviewed for incontinence care. The facility census was 46. Findings Include: An observation on 10/20/34 at 11:00 A.M. revealed Certified Nursing Assistant (CNA) #322 and CNA #209 completing incontinence care for Resident #13. CNA #322 had a basin with warm water sitting on the bedside table with a bottle of personal hygiene soap. CNA #322 placed the used washcloth on the bedside table. CNA used one washcloth to wash Resident #13's front peri-area and groin area, once washing was complete CNA #322 placed the used washcloth on the bedside table without a barrier. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure carpeting was maintained in a clean, sanitary and safe condition. This had the potential to affect all 44 residents residing in the facility. Findings Include: 1. Random intermittent observations on 06/30/24 between 8:00 A.M. and 4:00 P.M. revealed large numerous areas of stains on the carpeting through out the facility. Numerous instances of carpet peeling, creating a tripping hazard, were also noted through out the facility. Interview with the Administrator on 07/01/24 at 1:34 P.M. verified the condition of carpeting. The Administrator further stated areas (of the carpeting) were just replaced approximately six months ago. At this point in time, I do not believe it is in the budget to replace. 2. Observation of the dinning room sink on 07/02/24 at 12:00 P.M. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) contained all the necessary information. This affected two (Residents #6 and #8) of three residents reviewed for beneficiary notices. The facility census was 44.

Inspectors wroteBased on observations, staff, resident and family interviews, record review, and policy review, the facility failed to offer or provide Resident #194, who was dependent on staff for hygiene tasks, assistance with shaving. This affected one (Resident #194) of three residents reviewed for activities of daily living (ADL). The facility census was 44.

Inspectors wroteBased on observation, staff, family, and resident interview, record review, and policy review, the facility failed to provide a program of activities that met the needs and preferences of the residents. This affected three (Residents #3, #8, and #41) of four residents reviewed for activities. The facility census was 44.

Inspectors wroteBased on observation, staff interviews, medical record review, review of the Centers for Disease Control and Prevention (CDC) guidance on prevention of Catheter-Associated Urinary Tract Infections, and review of the facility policy, the facility failed to ensure residents urinary catheter bags were not resting on the floor. This affected two (Residents #20 and #28) of seven residents with urinary catheters. The facility census was 44.

Inspectors wroteBased on observation, review of survey history, and staff interview, the facility failed to ensure results of complaint investigations by the state survey agency were available as required. This had the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a representative of the Office of the State Long-Term Care (LTC) Ombudsman were notified of the residents transfers to the hospital. This affected 12 (Residents #14, #21, #40, #41, #42, #43, #145, #146, #147, #148, #149, and #195 ) reviewed for hospitalization and transfers and had the potential to affect all 44 residents currently residing in the facility.

Inspectors wroteBased on observation, review of maintenance repair logs, review of Resident Council meeting minutes, staff interview, Ombudsman interview, and review of manufacturer instructions, the facility failed to ensure processes were in place to ensure the resident call light system was tested and maintained in a fully functioning manner, and staff had required equipment to be alerted to resident call lights. This had the potential to affect all 44 residents residing in the facility. The census was 44.

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to ensure suprapubic urinary catheter dressing changes were completed as ordered. This affected one (#32) of three residents reviewed for dressing changes. The facility census was 44.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure wallpaper was not peeling and/or carpet was maintained in a clean manner/in good repair throughout the hallways of the facility. This had the potential to affect all 46 residents currently residing in the facility. Facility census was 46.

Inspectors wroteBased on review of the facility funds management system, and resident, family and staff interviews, the facility failed to obtain written authorization prior to opening resident personal needs accounts. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37.

Inspectors wroteBased on review of the facility funds management system, and resident, family and staff interviews, the facility failed to provide quarterly statements of account activity and failed to maintain resident fund records in a clear and understandable manner. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37.

Inspectors wroteBased on call light audit documentation, medical record review, and resident and staff interview, the facility failed to ensure call lights were answered in a timely manner. This affected three (#5, #21, and #35) of five reviewed for call lights. The census was 37.

Inspectors wroteBased on medical record review, and resident and staff interviews, the facility failed to bathe residents per their preference. This affected one (#2) of seven residents reviewed for bathing. The census was 37.

Inspectors wroteBased on medical record review, hospital discharge record review, and staff interview, the facility failed to confirmed a resident's code status upon admission to ensure accuracy. This affected one (#37) of 16 sampled residents reviewed for code status. The census was 37.

Inspectors wroteBased on observations, medical record review, and resident and staff interviews, the facility failed to provide adequate finger nail care for dependent residents. This affected two (#21 and #36) of four residents reviewed for activities of daily living (ADLs). The census was 37.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and review of an activity calendar, the facility failed to ensure activities met the needs of the residents. This affected two (#10 and #24) of 13 residents reviewed for activities. The census was 37.

Inspectors wroteBased on observations, medical record review, and staff interviews, the facility failed to provide pressure ulcers prevention interventions as indicated. This affected one (#36) of two residents reviewed for pressure ulcers. The census was 37.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to provide nutritional interventions as ordered. This affected one (#92) of two residents reviewed for nutrition. The census was 37.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#12) of four residents reviewed for medications. The census was 37.

Inspectors wroteBased on observation, resident, family, and staff interviews, and medical record review, the facility failed to timely follow up with dental services after a resident's dentures were lost. This affected one (#21) of seven residents reviewed for dental services. The census was 37.

Inspectors wroteBased on medical record review, review of hospital documentation, staff and physician interview and policy review, the facility failed to ensure staff thoroughly assessed a resident who was experiencing unrelieved abdominal pain to ensure the resident received timely treatment. This resulted in actual harm for Resident #8 when staff failed to assess and immediately report increased severe abdominal pain to the physician resulting in delayed emergency room treatment for uncontrolled pain and treatment of a perforated gastric ulcer. This affected one (#8) of one resident reviewed for a change in condition. The facility census was 43.

Inspectors wroteBased on observation, staff, resident and family interviews, review of a resident notice, review of a nursing services sign, review of a letter addressed to the Ohio Department of Health, review of the resident council minutes and policy review, the facility failed to ensure the resident call light system was timely repaired. This had the potential to affect all 43 residents residing in the facility. The facility census was 43.

Inspectors wroteBased on medical record review, observations, staff, resident and family interview, review of the facility activity calendar and policy review, the facility failed to provide a program of activities that met the residents needs and interests. This affected six (#20, #2, #38, #31, #7 and #37) of six residents reviewed for activities. The census was 43.

Inspectors wroteBased on observation, interview with facility staff, and review of a kitchen cleaning calendar, the facility failed to maintain the kitchen food preparation area and five oven its in a sanitary condition. This had the potential to affect all but one resident (#10-cannot consume oral nutrition). The census was 43.

Inspectors wroteBased on medical record review, observations, staff and resident interviews and review of the Resident [NAME] of Rights, the facility failed to ensure residents were afforded with their right to dignity. This affected two (#20 and #13) of two residents reviewed for dignity. This had the potential to affect all residents. The census was 43.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to complete Advanced Beneficiary Notices (ABN) as required for two (#33 and #248) of two residents reviewed who remained in the facility after being cut from skilled services and still had remaining Medicare Benefit days available for use. The facility identified two (#33 and #248) who had had remained in the facility after being discharged from skilled care and had remaining Medicare Benefits remaining in the last 180 days. Facility census was 43.

Inspectors wroteBased on observation, staff, resident and family interview and review of resident council minutes, the facility failed to ensure an adequate supply for towels and washcloths were available for resident use. This affected three (#18, #1 and #37) out of 17 residents sampled during the survey. The facility census was 43.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to accurately code the Minimum Data Set (MDS) assessment. This affected two (#2 and #44) of 14 residents reviewed for accurate MDS assessments. The census was 43.

Inspectors wroteBased medical record review and staff interview, the facility failed to screen two residents for serious mental illness and developmental disability prior to admission. This affected two (#1 and #43) of 14 residents reviewed for appropriate Pre-admission screens. The census was 43.

Inspectors wroteBased on medical record review, resident, family and staff interviews and review of facility policy, the facility failed to ensure showers were provided to a resident who required assistance with activities of daily living. This affected one (#43) of two residents reviewed for showers. The facility census was 43.

Inspectors wroteBased on medical record review, observations and resident and staff interviews, the facility failed to ensure a resident's hearing aid was maintained. This affected one (#26) of eight residents who wear hearing aids. The facility census was 43.

Inspectors wroteBased on medical record review, observation and interview with facility staff, the facility failed to provide preventative pressure ulcer interventions as care planned and physician ordered. This affected one (#2) of two residents reviewed for skin. The facility identified 36 residents receiving preventative skin care. Facility census was 43.

Inspectors wroteBased on medical record review, resident, family and staff interviews and review of facility policy, the facility failed to monitor a resident's weights weekly and failed to administer nutritional supplements per physician orders for a resident who was assessed as experiencing a significant weight loss before admission. This affected one (#43) of one resident reviewed for nutrition. The facility identified six residents at high risk for malnutrition and 25 residents receiving nutritional supplements. The facility census was 43.

Inspectors wroteBased on medical record review, staff interviews and review of facility policy, the facility failed to ensure the 13-valent pneumococcal vaccine (Prevnar-13) was offered to the residents. This affected three (#7, #20, #26) of five residents reviewed for influenza and pneumococcal vaccinations. The facility census was 43.