Winchester Gardens Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY COMPLAINT #2706331, 2717796 Based on interviews, review of medical records and other pertinent facility documentation on 2/19/26 and 2/20/26, it was determined that the facility failed to maintain a complete medical record when no evidence was provided that : 1) a private aide assigned to Resident #1 was educated on the resident's care needs, and 2) Resident #3's vital signs and pain level were assessed when their foley catheter became dislodged. This deficient practice was identified for 2 residents reviewed (Resident #1 & Resident #3) and was evidenced by the following:1). Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: mid-cervical fracture of the left femur, fracture of the right humerus, lack of coordination, and cognitive impairment. Review of Resident #1's comprehensive Assessment Minimum Data Set (MDS) an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

REPEAT DEFICIENCY Based on observation, interview, record review and policy review, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:On 9/2/2025 at 10:00 AM, in the presence of the Food Services Director, the surveyor observed the following: In the food preparation area, the surveyor observed a thick black grease-like substance on 3 of the 12 burner stoves. The residue was easily dislodged using the tip of a pen. NJAC 8:39-17.2(g)

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 1 (one) of 12 residents (Resident #23) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 9/3/25 at 11:38 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who stated that in April, she thought that she had submitted the Resident #23 admission MDS (A/MDS) assessment. The MDSC/RN revealed that she did not submit the assessment on time. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to follow up on the psychiatry (psych) consult recommended by the physician to address the dementia care of a resident who is receiving antipsychotic medications. This deficient practice was identified for 1 (one) of 1 resident (Resident #2) reviewed for dementia care. This deficient practice was evidenced by the following: On 9/3/25 at 12:20 AM, the surveyor observed Resident #2 sitting in a wheelchair inside the dining room having lunch. On 9/4/25 at 11:51 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #2, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #2 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity, with other behavioral disturbance. A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization and provide education regarding the vaccine. This deficient practice was identified for 1 of 5 residents reviewed for immunization (Resident #12).On 09/3/25 09:59 AM, the surveyor reviewed Resident #12's medical record which revealed the following information: A review of the Resident's Face Sheet (an admission summary) revealed Resident # 12 had been admitted to the facility with diagnoses which included hemiplegia following cerebral infarction affecting the right dominant side and chronic kidney disease. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 8/25/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of Resident #12's active Care Plan (CP) printed on 9/5/25 did not reveal any focus, goals, or interventions for vaccinations. A review of Resident #11's electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY REPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This repeat deficient practice was observed and evidenced by the following: On 5/28/24 at 06:01 PM, while on 4th floor, in the area labeled Den, the surveyor observed a staff refrigerator with signage that stated, all items must be labeled with name and date. The surveyor observed a 2 liter bottle of Coke Cola, a container of salad and brown bag with a container of food. All items were missing labels including names and dates. On 5/28/24 at 6:24 PM, the surveyor in the presence of the Executive Chef (EC) observed the following during the kitchen tour: 1. Upon entering the kitchen the surveyor observed two servers (dietary aides) server #1 and #2 with hair not fully restrained, servers #3 and #4 without hairnets, and server #5 with beard guard improperly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 6 of 15 residents reviewed (Resident # 4, 17, 19, 7, 11, 18). This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #4. According to the admission Record (AR) (an admission summary), Resident #4 had diagnoses that included but were not limited to: Hypertension, Glaucoma, Anemia and Chronic Obstructive Pulmonary Disease. A Quarterly Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 5/21/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 6 out of 15, which indicated the resident had severe cognitive impairment. A review of physician progress notes (PPN) in the hybrid medical record revealed there were no physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from the medication room and treatment cart. This deficient practice was identified for 1 of 1 floor inspected and was evidenced by the following: On 05/28/24 7:45 PM, the surveyor inspected the 4th floor medication storage room and treatment cart (high side) in the presence of the Licensed Practical Nurse and found the following expired medication: a. 2 bottles of Adult low dose Enteric Coated 81mg that had 120 tablets each bottle with an expiration date of 8/2023 b. 1 tube of unopened Bacitracin Ointment 1 oz (28.4g) with an expiration date of 1/2024. c. 1 tube of opened Bacitracin Ointment 1 oz (28.4g) with an expiration date of 1/2024 inside the treatment cart. On 5/28/2024 at 8:30 PM, the surveyor discussed the above concern to the facility's Licensed Nursing Home Administrator, Director of Nursing and Assisted Living Coordinator who acknowledged that the above medications were expired. NJAC 8:39-29.2 (d)

Based on observation, interview, and review of facility policy, the facility failed to: 1. ensure food was stored in a sanitary manner; 2. ensure dishes and pans were air dried and not dried by a standing fan that had dust on it; 3. ensure kitchen equipment was clean; 4. ensure proper hand hygiene while handling food; 5. ensure sanitizing buckets used to sanitize counters was adequate; and 6. ensure steam tables had water in them to keep food at the appropriate temperature. These failures had the potential to affect 17 out of the 18 residents who ate food prepared by the kitchen. Findings include: The following observations in the kitchen were made with and verified by the Director of Culinary Services (DCS) and the Resource Chef (Chef): 1. On 09/28/22 at 8:30 AM, observation, of the refrigerator revealed one jar of mayonnaise with a cracked lid that prevented it from being sealed closed. On 09/28/22 at 8:34 AM, observation of the main kitchen area revealed a large plastic bin under the counter that contained rice flour with a dried liquid dripped into the container. The second…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to obtain a Code Status for one resident (Resident (R) 8) out of a total sample of 10 residents. This failure had the potential for R8 to have unwanted life-sustaining treatments. Findings include: 1. Review of R8's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R8 was admitted to the facility on [DATE]. There was no Advance Directive, Physician Orders for Life Sustaining Treatment (POLST), or a Code Status in the EMR or in the resident's hard chart located in the nursing office. Review of the EMR Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R8 had no cognitive impairment. Interview on [DATE] at 9:00 AM with Registered Nurse (RN) 2 revealed that the facility process was that the code status for Do Not Resuscitate (DNR) was located on the binder of the resident's hard chart in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide timely a completed Centers for Medicaid and Medicare Services (CMS) Form CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to one of three residents (Resident (R) 64) reviewed for liability notices out of a total sample of 10 residents. This failure prevented the resident or responsible party the ability to make an informed decision related to the cost of continued services. Findings include: 1. Review of R64's Face Sheet, undated and located in the resident's electronic medical record (EMR) under the Profiles tab, indicated a current admission date to the facility of 03/08/22, with diagnoses which included; acute on chronic congestive heart failure (CHF), difficulty in walking, and unsteadiness on feet. Review of R64's Progress Notes, located in the EMR under the Assessments tab, indicated R64 was admitted to Medicare part A therapy services on 03/08/22. Further review of R64's EMR indicated R64's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.