Winchester Health & Rehab: Missed Medications on Admission - VA
Federal inspectors documented the lapse during a complaint inspection completed September 11, 2025. The resident, identified in records only as R1, had no cognitive impairment. He was alert and oriented. He received hemodialysis three times a week. He was, by the facility's own notes, pleasant and cooperative with staff when he arrived in his wheelchair that afternoon.
His orders were clear: 15 units of Insulin Glargine every night shift, Coreg twice daily for high blood pressure, Midodrine twice daily for low blood pressure. Managing both high and low blood pressure in the same patient is a delicate balance. Missing either medication disrupts it.
The May 2025 medication administration record showed all three went undelivered that evening. The documented reason for the missed insulin was "new admit on order," a note suggesting the nurse believed the prescription hadn't yet come through. The Coreg and Midodrine were recorded as not given as well.
But inspectors pulled the facility's Omnicell records, the electronic cabinet that holds commonly used medications for immediate access. At 5:00 p.m. on May 20, the Omnicell contained Insulin Glargine 100 units per milliliter, Coreg 3.125 mg tablets, and Midodrine 5 mg. The drugs were there. They were not administered.
The assistant director of nursing, interviewed September 9, explained how the system is supposed to work. Orders for new residents go into the electronic medical record and transmit directly to the pharmacy, which delivers as quickly as possible, with the option for a stat delivery when needed. She said nurses are supposed to check the Omnicell before concluding a medication is unavailable. If a drug still can't be obtained, staff should ask the family to bring it from home. And if a medication cannot be given, she said, the physician must be notified so the doctor can either order a substitute or explicitly decide it is acceptable for the resident to go without it temporarily.
None of that happened for R1 on his first night.
The physician was not called. No substitute was ordered. No family member was asked to bring anything. The nurse did not check the cabinet, or checked it and reached the wrong conclusion, or never documented any attempt at all. The record shows only that the medications were marked not given, with a notation about a new admission.
For a dialysis patient managing competing blood pressure conditions, the stakes of a missed dose are not abstract. Hemodialysis itself causes significant blood pressure swings. Midodrine is often prescribed specifically to counteract the drops that occur during and after treatment. Coreg controls the elevated readings. Missing both on the same night, in a patient with kidney failure severe enough to require dialysis three times a week, is not a minor clerical oversight.
The inspection cited the deficiency under federal tag F0684, which covers the standard of care residents are entitled to receive. Inspectors rated the level of harm as minimal or potential for actual harm, and noted few residents were affected.
The administrator and director of nursing were informed of the findings on the afternoon of September 9. No additional information was provided before inspectors left the building.
R1 had just arrived. He was alert. He knew who he was and where he was. Whether he knew that night that three of his medications had been skipped, the record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winchester Health & Rehabilitation from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
WINCHESTER HEALTH & REHABILITATION in WINCHESTER, VA was cited for violations during a health inspection on September 11, 2025.
Federal inspectors documented the lapse during a complaint inspection completed September 11, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.