Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winchester Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Medication administration errors exceeded the acceptable rate when an LPN made multiple errors during a medication pass, resulting in a 24% error rate. A resident with CHF, chronic respiratory failure, DM2, CKD, hypertension, hyperkalemia, and a pacemaker received several scheduled meds more than 2 hours late, and the nurse did not follow inhaler technique directions or the timing requirements for sodium polystyrene sulfonate with other oral meds. The nurse said the unit was busy and she stopped to hand out meal trays, and she did not notify the NP or MD about the late meds.
A resident with DM, CKD, GERD, vitamin deficiency, and vascular dementia experienced a significant weight loss that was not promptly identified because required weights were not obtained and reviewed. The resident's nutrition assessment was completed just before the loss was documented, no additional dietary assessment was done after the loss, and a requested reweight was not shown as completed in the record.
Significant medication administration delays and omissions: A nurse was behind on the med pass and failed to give multiple 9:00 A.M. meds as ordered for four residents, including meds for CHF, HTN, DM, AFib, MRSA, COPD, and C. difficile. One resident received meds more than 2 hours late, while the MARs for the others did not show administration or refusal. The nurse said she was delayed by passing meal trays and did not notify the provider; the UM, NP, and DON stated meds must be given as ordered and delays reported.
The facility failed to secure medication rooms, allowing unauthorized access. Surveyors observed a nurse loudly disclosing the code to a medication room, and codes were posted visibly in some areas. Various medications and kits were found unsecured, and interviews confirmed that only nurses should have access. This indicates a breach in security protocols.
A facility failed to document advance directives for a resident with multiple diagnoses, including Parkinson's Disease and diabetes. The care plan indicated DNR/DNI status, but the medical record lacked a MOLST form or physician order. Staff interviews revealed discrepancies in the resident's code status documentation, with a Unit Manager and the DON acknowledging the absence of necessary documentation.
The facility failed to implement and develop comprehensive care plans for three residents. A resident with cerebral vascular disease was not wearing a prescribed left-hand splint, and there was no documentation of refusal. Another resident with a pacemaker had an incomplete care plan lacking essential details and monitoring records. A third resident on anticoagulants did not have a care plan addressing bleeding risks. Interviews confirmed the deficiencies in care plan implementation and documentation.
A resident with a history of myocardial infarction and heart failure experienced a significant weight loss, which was not monitored according to the physician's order for weekly weights. The facility failed to document weekly weights and did not conduct necessary nutritional assessments, as confirmed by interviews with the dietician, ADON, and DON. This resulted in a deficiency in the quality of care provided.
A facility failed to adhere to professional standards for enteral tube feeding administration for a resident with specific nutritional needs. Observations revealed that tube feeding bags were not labeled or dated, contrary to facility policy and physician's orders. Interviews with staff confirmed the requirement for labeling and dating, highlighting a deficiency in care.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care documentation. One resident's left-hand splint was not documented correctly, and another resident's tube feeding start time was inaccurately recorded. Observations and staff interviews confirmed discrepancies between documented and actual care provided.
A facility failed to provide a resident's Health Care Agent (HCA) with requested medical records within the required timeframe due to the HCA's refusal to sign a release form containing a liability clause. Despite multiple requests, the facility adhered to its policy requiring a signed form, resulting in the denial of the records. The HCA, activated due to the resident's dementia, was uncomfortable with the liability release, leading to the deficiency.
The facility failed to provide complete discharge notices to three residents, omitting essential information required by federal regulations. Notices lacked details such as the reason for discharge, effective date, and appeal rights. The issue was discovered after incomplete notices were sent to residents and their representatives, with the DON realizing the error following a discussion with the Ombudsman Program Manager.
Medication Administration Errors Exceeded Acceptable Rate
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when one of four nurses observed made six errors out of 25 opportunities, resulting in a 24% medication error rate. The errors affected one resident out of nine residents observed. The facility policy required medications to be administered by licensed nurses or other authorized staff in accordance with physician orders and professional standards, including comparing the medication source with the MAR and administering medications according to manufacturer specifications. For one resident with diagnoses including CHF, chronic respiratory failure with hypoxia, type 2 DM, interstitial pulmonary disease, PVD, CKD stage four, hypertension, hyperkalemia, and a cardiac pacemaker, Nurse #1 administered scheduled medications 2 hours and 36 minutes late. The medications included nifedipine ER, NovoLIN N insulin, sodium polystyrene sulfonate suspension, Breyna inhalation aerosol, carvedilol, and cefpodoxime proxetil. The resident’s most recent MDS indicated moderate cognitive impairment and that the resident required partial assistance from staff for all ADLs. During the medication pass, Nurse #1 did not wait 10 seconds between sprays and did not shake the Breyna inhaler for 5 seconds before the second spray, contrary to the manufacturer’s directions. The manufacturer’s guidelines for sodium polystyrene sulfonate indicated it should be administered at least 3 hours before or after other oral medications, but the resident received it during the same medication pass as other oral medications. In interview, Nurse #1 said the unit was busy and she stopped the medication pass to hand out meal trays, acknowledged medications should be given within one hour of the scheduled time, and said she did not notify the NP or physician when the medications were more than one hour late. The Unit Manager, NP, and DON each stated medications must be administered as ordered and within the correct time frame, and that delays or missed administration should be reported to the physician.
Failure to Monitor Weight Loss and Complete Nutrition Assessment
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for Resident #12 when the facility failed to obtain weights as required, which delayed identification of a significant weight loss, assessment of that loss, and implementation of interventions. The resident was admitted with diagnoses including diabetes mellitus with diabetic chronic kidney disease, hyperlipidemia, gastroesophageal reflux disease, deficiency of other vitamins, and vascular dementia. The most recent MDS indicated the resident was rarely or never understood, unable to complete BIMS, and required staff assistance for all ADLs. The resident's weight record showed 143.0 lbs. on 12/3/25, then 126.2 lbs. on 1/15/26, a loss of 11.68% of total body weight, followed by a documented weight of 142.5 lbs. on 1/23/26 that was struck out as incorrect documentation, and 126.0 lbs. on 2/3/26. The quarterly nutrition assessment had been completed two days before the documented weight loss, and no additional dietary assessment was completed after the loss was identified. A risk note dated 1/22/26 indicated a reweight was requested, but the record did not show that a re-weigh was completed or that the weight change was reviewed at risk meetings. The care plan directed monitoring of PO intake, weights, labs, and skin, and staff interviews indicated weights were typically collected by CNAs and entered by nursing staff, with reweights and dietitian notification occurring when needed.
Significant medication administration delays and omissions
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for four residents. During observation and record review, Nurse #1 was behind on the medication pass and had not administered multiple 9:00 A.M. medications for Residents #94, #126, #86, and #51. The report states that the medications were not given in accordance with physician orders, and for several residents the MAR did not show the medications had been administered and the records did not indicate refusal. For Resident #94, who had diagnoses including CHF, chronic respiratory failure with hypoxia, type 2 diabetes mellitus, interstitial pulmonary disease, peripheral vascular disease, severe CKD stage four, hypertension, hyperkalemia, and a pacemaker, Nurse #1 administered the morning medications at 11:36 A.M., which was 2 hours and 36 minutes after the scheduled time. The medications included nifedipine ER, Novolin N insulin, carvedilol, cefpodoxime, and sodium polystyrene sulfonate. The report also notes the manufacturer’s guidance for sodium polystyrene sulfonate that it be administered at least 3 hours before or after other oral medications. For Resident #126, whose diagnoses included hypertension, CHF, atrial fibrillation, dilated cardiomyopathy, and MRSA, the active orders included digoxin, furosemide, metoprolol succinate ER, apixaban, and doxycycline due at 9:00 A.M. The MAR failed to show these medications were administered, and the record did not show refusal. Nurse #1 stated she had not given the medications because she was running late and behind on her medication pass, and she did not notify the physician. For Resident #86, with diagnoses including type 2 diabetes mellitus, COPD, heart failure, atrial flutter, chronic systolic CHF, hypertension, major depressive disorder, and anxiety, the morning orders included duloxetine, furosemide, losartan, metformin, spironolactone, metoprolol succinate ER, and apixaban. The MAR did not indicate administration and the record did not show refusal. Nurse #1 again stated she had not administered the medications because she was behind on her medication pass and had not notified the physician. For Resident #51, who had diagnoses including acute respiratory failure with hypoxia, asthma, type 2 diabetes mellitus, atrial fibrillation, C. difficile enterocolitis, pneumonia, hypertension, right peroneal vein thrombosis, anemia, peripheral vascular disease, and myocarditis, the morning orders included apixaban, metoprolol succinate ER, and vancomycin. The MAR did not show administration and the record did not show refusal. Nurse #1 stated she had not given the medications because she was running late and did not notify the physician. Interviews with the Unit Manager, NP, and DON confirmed that medications were to be administered as ordered and that delays or missed doses were to be reported.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in accordance with accepted professional standards of practice. During observations, surveyors noted that the codes to medication rooms were disclosed to unauthorized personnel. Specifically, a nurse loudly yelled the code across the hall, allowing residents and staff members in the hallway to hear it. Additionally, surveyors were able to independently access medication rooms in multiple units, indicating that the security of these areas was compromised. In each of the medication rooms accessed, various medications and kits were found, including insulin vials, over-the-counter medications, and emergency kits. Interviews with unit managers and the Director of Nursing confirmed that only nurses should have access to these rooms and know the codes. However, the presence of the code posted above the padlock in one unit further demonstrated the lack of adherence to security protocols. This breach in security measures highlights the facility's failure to restrict access to medication rooms to authorized personnel only.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were consistently documented in the medical record for a resident. The resident, who was admitted with diagnoses including adult failure to thrive, anxiety disorder, Parkinson's Disease, diabetes, and hallucinations, had a care plan indicating Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status. However, the medical record lacked a Physician Orders for Life-Sustaining Treatment (MOLST) form or a physician order reflecting this status. Additionally, there was no documentation in the nursing progress notes indicating that the code status was discussed upon admission. Interviews with facility staff revealed discrepancies in the resident's code status documentation. A Unit Manager stated that the resident was a full code and acknowledged the absence of a MOLST form, which should have been present to match the care plan. The Director of Nurses confirmed the lack of a MOLST form in the medical record and indicated that the care plan would be updated to reflect the correct code status. A Social Worker also noted that the resident should have a MOLST form indicating the code status in the chart.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a care plan for Resident #23, who was admitted with diagnoses including cerebral vascular disease and hemiplegia. Despite a physician's order to apply a left-hand grip splint daily, observations over two days showed that the resident was not wearing the splint at any time. Interviews with the Unit Manager and Director of Nursing confirmed that the splint schedule should be followed as ordered, and there was no documentation of the resident refusing to wear the splint. For Resident #13, the facility did not develop a comprehensive pacemaker care plan. The resident, who has severe cognitive impairment and a cardiac pacemaker, reported that nobody checks the pacemaker. The care plan lacked essential details such as the date of insertion, model, serial number, and cardiologist contact information. Interviews revealed that the pacemaker care plan was incomplete, and there was no record of recent pacemaker monitoring in the medical record. Resident #48, who is cognitively intact and taking an anticoagulant, did not have a care plan addressing the risks associated with high-risk medications. The care plan failed to include interventions related to bleeding risks, despite the resident being on Apixaban. Interviews with the Unit Manager and Director of Nursing confirmed that the care plan should have been updated to reflect the bleeding risks due to the anticoagulant medication.
Failure to Monitor and Document Resident's Weight Loss
Penalty
Summary
The facility failed to provide services that met professional standards of quality for a resident who was admitted with diagnoses including myocardial infarction, diastolic congestive heart failure, and paroxysmal atrial fibrillation. The resident, who was cognitively intact, experienced a significant weight loss of 6.2% in one month, which was not properly monitored as per the physician's order for weekly weights. The facility's policy required weights to be recorded and analyzed for significant changes, with the physician and dietitian to be informed and consulted for interventions. However, the resident's weight was not documented weekly, and there was no evidence of re-weighs or nutritional assessments being completed during the period of significant weight loss. Interviews with the dietician, Assistant Director of Nurses (ADON), and Director of Nurses (DON) revealed that the facility did not adhere to its weight monitoring policy. The dietician acknowledged the need for weekly weight monitoring and assessments, which were not conducted. The ADON and DON confirmed that weights should have been completed, documented, and discussed in risk meetings, with care plan interventions updated accordingly. The lack of documentation and follow-up on the resident's significant weight loss indicated a failure to implement the physician's orders and the facility's policy, resulting in a deficiency in the quality of care provided.
Failure to Label and Date Tube Feeding Bags
Penalty
Summary
The facility failed to adhere to professional standards of practice for the administration of enteral tube feeding for a resident diagnosed with encephalopathy, dysphagia, and type 2 diabetes mellitus. The resident was admitted in November 2024 and had a physician's order for tube feeding via a gastric tube with specific instructions for the type and amount of nutrition to be administered. However, during observations on two consecutive days, the surveyor noted that the tube feeding bags used for the resident were not labeled with the type of formula or dated to indicate when the formula was first administered and when it should expire. Interviews with the Unit Manager and the Director of Nursing confirmed that the facility's policy required tube feeding bags to be labeled and dated to ensure proper administration and monitoring. Despite this policy, the staff did not consistently follow these procedures, leading to a deficiency in the care provided to the resident. The lack of labeling and dating of the tube feeding bags was a deviation from the facility's established protocol and the physician's orders, which are essential for ensuring the resident's nutritional needs are met safely and effectively.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care documentation. For one resident, who was admitted with cerebral vascular disease and severe cognitive deficits, the facility did not accurately document the wearing of a left-hand splint. Despite physician orders and care plan interventions indicating the splint should be worn daily as tolerated, observations over two days showed the resident was not wearing the splint at any time. The Treatment Administration Record inaccurately indicated that the splint was being worn, and there was no documentation of the resident refusing to wear it. For another resident, admitted with encephalopathy, dysphagia, and type 2 diabetes mellitus, the facility failed to accurately document the start time for tube feeding as ordered by the physician. The physician's order specified that the tube feeding should start at 8:00 PM, but the medical record system incorrectly recorded the start time as 2:00 PM. Observations confirmed that the resident was receiving tube feeding at the correct time, but the Medication Administration Audit Report showed that staff signed off on the feeding as if it had started at the incorrect time. Interviews with facility staff, including unit managers and the Director of Nursing, revealed that the documentation did not reflect the actual care provided. Staff acknowledged that the splint was not worn as documented and that the tube feeding was not administered at the times recorded. The Director of Nursing emphasized the importance of accurate documentation and the need to address discrepancies in order timing and treatment administration.
Failure to Provide Medical Records to Health Care Agent
Penalty
Summary
The facility failed to provide a resident's Health Care Agent (HCA) with copies of medical records within the required two working days, as mandated by federal regulations. The HCA, who was activated as the resident's legal representative due to the resident's moderate to severe dementia, made multiple requests for the resident's lab results both verbally and through email. Despite these requests, the facility did not provide the requested documentation, citing the HCA's refusal to sign an Authorization For Release Of Information form that included a liability release clause. The facility's policy required a signed release form before providing copies of medical records, and staff members, including the Medical Records Coordinator, Director of Nurses, and Nursing Supervisor, adhered to this policy. The HCA expressed discomfort with the liability release clause in the form and refused to sign it, leading to the denial of the requested records. The HCA had previously signed the form but chose not to do so on this occasion, fearing it would prevent her from pursuing legal action against the facility. Interviews with facility staff confirmed that the HCA's requests were acknowledged but not fulfilled due to the unsigned release form. The Director of Nurses indicated that the facility's owner had consulted with their legal department and offered to provide the records without the signed form, but this offer was made after the deficiency was identified. The facility's policy and the HCA's refusal to sign the form were central to the failure to provide the requested medical records in a timely manner.
Incomplete Discharge Notices Issued to Residents
Penalty
Summary
The facility failed to provide complete and timely notification of discharge to residents, their legal representatives, or Health Care Agents (HCA) as required by federal regulations and facility policy. This deficiency was identified for three residents. The facility's Transfer and Discharge Policy mandates that a Notice of Intent to Discharge must include specific information such as the reason for discharge, effective date, location, appeal rights, and contact information for relevant state entities. However, the facility did not adhere to this policy, as evidenced by incomplete notices being issued. For Resident #1, the Assistant Director of Nurses (ADON) sent an incomplete notice to the hospital and left a copy in the resident's medical record, unaware that the notice required three pages. The Director of Nurses (DON) later mailed the incomplete notice to the HCA and only realized the omission after a conversation with the Ombudsman Program Manager. Similarly, for Residents #2 and #3, the notices lacked complete information, including the date and location of discharge, and the additional pages were not provided. The DON discovered that the blank copies of the notice available to staff were incomplete, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,389 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aberjona Rehabilitation And Nursing Center | 0 mi | ★★★★★ | 0 | 0 |
| Park Avenue Health Center | 2.2 mi | ★★★★★ | 10 | 0 |
| Woburn Rehabilitation And Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Care One At Lexington | 2.5 mi | ★★★★★ | 11 | 0 |
| Regalcare At Courtyard-medford | 2.6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Winchester Rehabilitation And Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.