Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Nursing Center, Inc during CMS and state inspections, most recent first.
Failure to provide written transfer notices: The facility did not document that two residents were given written notice of hospital transfers, including the reason for transfer, when they were sent out and later readmitted. The policy required transfer notice to be provided to the resident and representative as soon as practicable, but records showed no written notification for the transfers, and staff said forms were completed and given to the resident before leaving.
The facility failed to maintain a clean and homelike environment, as evidenced by stained privacy curtains in multiple resident rooms. Residents and staff confirmed the curtains had not been cleaned recently, and there was a lack of clear procedures and communication for addressing this issue.
The facility failed to follow physician's orders for daily weights for a resident with congestive heart failure. Multiple missed opportunities for recording daily weights were identified in the resident's medical chart. Interviews with an LPN and the DON confirmed the documentation requirements, but the facility did not provide a relevant policy.
The facility failed to follow standards of practice for a resident with an indwelling catheter, lacking physician orders for the catheter, regular changes, and documentation. Observations and staff interviews confirmed these deficiencies.
The facility failed to document ongoing assessments, monitoring, and communication between the facility and the dialysis center for two residents. This included missed opportunities to obtain weights, vital signs, and check the bruit and thrill as ordered, as well as inconsistent pre-and post-dialysis communication.
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate due to improper insulin pen administration. LPNs did not prime the insulin pens as required, affecting five residents. Interviews revealed a lack of understanding of the correct procedures.
The facility failed to provide a safe and sanitary environment by not performing hand hygiene during medication administration for five residents and not disinfecting the glucometer per the manufacturer's instructions for three residents. LPNs were observed failing to perform hand hygiene before and after using gloves, and not sanitizing the glucometer between resident uses.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing of hospital transfers, including the reason for the transfer, for two of nine sampled residents. Review of the facility policy titled, Transfer or Discharge Notices, revised March 2025, stated that when a resident is sent emergently to an acute care setting, it is considered a transfer and that notice of transfer is to be provided to the resident and representative as soon as practicable before the transfer, and to the LTC ombudsman when practicable. Resident #30 was transferred to the hospital on two occasions and later readmitted to the facility, but there was no documentation that the resident and/or resident representative was informed in writing of either transfer at the time they occurred. Resident #52 was also transferred to the hospital and later readmitted, and there was no documentation that the resident and/or resident representative was informed in writing of that transfer. During interviews, an LPN stated nurses talked to the resident about the transfer and bed hold policy and the SSD completed the forms, which were then given to the resident before leaving. The SSD stated the forms were filled out and given to the resident before departure, and if the SSD was not working, the nurse was responsible for the process. The Administrator stated that when a resident was sent out for any reason, the resident sometimes did not want the family or responsible party notified and the facility would do what the resident wished.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment, as evidenced by multiple observations of stained and unclean privacy curtains in resident rooms. Specifically, observations on three different dates revealed large stained areas on privacy curtains in rooms on both the 100 Hall and 200 Hall. Residents confirmed that the curtains had been stained for a while and could not recall the last time they were cleaned. Housekeeping staff were unaware of a daily checklist for cleaning privacy curtains and had not recently identified any curtains needing cleaning. The housekeeping cleaning schedule and daily checklist did not address privacy curtains. Interviews with housekeeping staff and the maintenance supervisor indicated a lack of communication and clear procedures for identifying and cleaning stained privacy curtains. The Administrator expected housekeeping to check and notify maintenance about stained curtains, but this was not happening consistently. The facility's policy emphasized providing a clean and homelike environment, but the observations and interviews demonstrated a failure to adhere to this policy, potentially affecting all residents in the facility.
Failure to Follow Physician's Orders for Daily Weights
Penalty
Summary
The facility failed to follow physician's orders for daily weights for one resident diagnosed with congestive heart failure. The resident's Physician Order Sheet indicated a daily weight order starting from March 21, 2024. However, the resident's medical chart showed multiple missed opportunities for recording daily weights: three missed out of 11 in March, 12 missed out of 30 in April, and five missed out of eight in early May. Interviews with an LPN and the DON confirmed that daily weights should be documented in the Treatment Administration Record or the computer's vital tab, and any refusals should be noted in the progress notes. The facility did not provide a policy regarding this procedure.
Failure to Follow Standards for Indwelling Catheter Care
Penalty
Summary
The facility failed to follow standards of practice regarding the care of a resident with an indwelling catheter. Specifically, the facility did not have a physician's order for the catheter, did not obtain orders to change the catheter every 30 days, and did not ensure documentation of catheter changes for one resident. Observations on multiple days showed the resident with a visible catheter bag, and interviews with staff revealed that there were no orders specifying the catheter size or frequency of changes. The hospice case manager confirmed that hospice would only change the catheter if there was a problem, and there were no standing orders for regular catheter changes or specifications on catheter size.
Failure to Document Dialysis Care and Communication
Penalty
Summary
The facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis center for two residents. For Resident #40, the facility did not have an order for dialysis with specific days, missed several opportunities to obtain weights, vital signs, and check the bruit and thrill as ordered. Additionally, there was inconsistent pre-and post-dialysis communication with the dialysis center. The resident's care plan indicated the need for dialysis and the associated risks, but the required assessments and documentation were not consistently performed or recorded. Similarly, for Resident #42, the facility did not have an order for dialysis with specific days and missed multiple opportunities to obtain weights, vital signs, and check the bruit and thrill as ordered. The facility also failed to provide consistent pre-and post-dialysis communication with the dialysis center. The resident's care plan highlighted the need for dialysis and the associated risks, but the necessary assessments and documentation were not consistently carried out. Interviews with staff, including an LPN and the DON, confirmed that the required weights, vital signs, and assessments should have been documented as ordered. The DON emphasized that any refusals by residents should also be documented in the progress notes. The facility's failure to adhere to these protocols resulted in missed opportunities for monitoring and communication, which are critical for residents undergoing dialysis.
Failure to Maintain Medication Error Rate Below 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 12% for five residents. The errors were primarily due to the improper administration of insulin using Kwik Pens and Flex Pens. Specifically, the Licensed Practical Nurses (LPNs) did not prime the insulin pens as per the manufacturer's instructions before administering the medication to the residents. This failure was observed in multiple instances involving different residents and types of insulin pens, including Humalog/lispro and Novolog/aspart pens. For Resident #9, LPN D administered 2 units of lispro insulin without priming the Kwik Pen, as required by the manufacturer's instructions. Similarly, for Resident #25, LPN D administered 6 units of Novolog insulin without priming the Flex Pen. Resident #28 also received 3 units of Novolog insulin from LPN G without the pen being primed. These actions were repeated for Resident #34 and Resident #42, where LPN D and LPN G, respectively, failed to prime the insulin pens before administration. Interviews with the staff revealed a lack of understanding and adherence to the correct insulin pen administration procedures. LPN G incorrectly believed that priming was only necessary when the pen was new and not for subsequent uses. The Director of Nursing (DON) and the Administrator both confirmed that the expectation was to prime the pen needle with 1-2 units of insulin before administering the prescribed dose and to hold the pen to the skin for a few seconds after administration. This discrepancy between the expected procedure and the actual practice led to the medication errors observed during the survey.
Failure to Perform Hand Hygiene and Disinfect Glucometer
Penalty
Summary
The facility failed to provide a safe and sanitary environment by not performing hand hygiene during medication administration for five residents and not disinfecting the glucometer per the manufacturer's instructions for three residents. Specifically, LPNs were observed failing to perform hand hygiene before and after using gloves, and not sanitizing the glucometer between resident uses. This was observed during blood glucose testing and insulin administration for Residents #9, #25, #28, #34, and #42. The facility's policies on blood sampling and infection control were not followed, as the glucometer was not disinfected between uses, and hand hygiene was not performed as required. Interviews with the ADON, Administrator, and DON confirmed that the expected procedures were not adhered to, including the use of Sani-Cloth wipes to disinfect the glucometer and performing hand hygiene between tasks and glove changes.
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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.
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Nursing homes near Bernie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Malden | 6.5 mi | ★★★★★ | 0 | 0 |
| Memory Lane Of Dexter | 8.4 mi | ★★★★★ | 0 | 0 |
| Cypress Point-skilled Nursing By Americare | 8.9 mi | ★★★★★ | 7 | 0 |
| Crowley Ridge Care Center | 10 mi | ★★★★★ | 0 | 0 |
| Campbell Healthcare & Senior Living | 13.8 mi | ★★★★★ | 15 | 0 |
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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.