Inspection Reports for
Winchester Gardens

The facility was found deficient in multiple areas including failure to timely complete and transmit a Minimum Data Set (MDS) assessment, failure to follow up on a psychiatry consult for a resident with dementia on antipsychotic medications, unsanitary kitchen conditions with grease residue on stoves, and failure to offer and document COVID-19 immunization education and administration for a resident.

Complaint #: NJ173628. Complaint investigations were completed during this survey.

Deficiencies were cited related to expired medications in storage, improper food labeling and sanitation practices in the kitchen, incomplete and inaccessible medical records for multiple residents, failure to annually review the emergency preparedness plan, fire safety code violations including non-fire rated soiled linen room door, fire alarm system trouble, lack of fire watch policy for sprinkler system outages, and incomplete electrical receptacle testing.

The facility was found deficient in removing expired medications from storage areas, maintaining proper kitchen sanitation and food labeling practices, and ensuring complete and accessible physician progress notes in residents' medical records. These deficiencies were observed through direct observation, interviews, and record reviews.

The facility was found deficient for failing to maintain the required minimum direct care staff-to-resident ratios on one evening shift (September 13, 2022). The deficiency involved having 2 certified nurse aides (CNAs) instead of the required 3 on that shift. A plan of correction was initiated including staff in-service training and ongoing monitoring.

The visit was complaint-related involving issues with code status documentation for Resident 8, Medicaid/Medicare liability notice provision for Resident 64, and food safety concerns affecting multiple residents.

The facility failed to document a resident's code status leading to potential unwanted life-sustaining treatments, failed to provide timely and complete Medicaid/Medicare liability notices to a resident, and failed to maintain sanitary food storage, preparation, and serving conditions in the kitchen, potentially affecting multiple residents.