Winchester Health & Rehab: Missed Medications on Admission - VA
The resident, identified in inspection records only as Resident 1, receives hemodialysis three days a week and carries orders for Insulin Glargine injected every night shift, Coreg twice daily for high blood pressure, and Midodrine twice daily to treat low blood pressure. His medication administration record documented the missed doses on the evening of May 20 with a note attributing the gap to his being a new admit with orders still pending.
Inspectors pulled the facility's Omnicell inventory log for that same day. At 5:00 p.m. on May 20, all three medications were listed as available: Insulin Glargine 100 units per milliliter, Coreg 3.125 mg tablets, and Midodrine 5 mg.
The assistant director of nursing, interviewed on September 9, acknowledged the Omnicell contains many standard medications and that nurses are expected to check it before concluding a drug is unavailable. She said the facility can also request stat delivery from the pharmacy. If a medication genuinely cannot be obtained, she said, the physician should be notified and given the opportunity to order an alternative or weigh in on whether a dose can safely be skipped.
None of that happened on Resident 1's first night.
The administrator and director of nursing were informed of the findings the same afternoon inspectors reviewed the records. No additional information was provided before the inspection closed.
Resident 1 had no cognitive impairment. He could have told someone he hadn't received his medications. Whether anyone asked him is not reflected in the record.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
WINCHESTER HEALTH & REHABILITATION in WINCHESTER, VA was cited for violations during a health inspection on September 11, 2025.
Inspectors pulled the facility's Omnicell inventory log for that same day.
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.