Winchester Health & Rehabilitation
Inspection Findings
F-Tag F0558
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, resident interview, staff interview, clinical record review and facility document review,
it was determined that the facility staff failed to maintain a call bell in a position that was accessible to the resident for one of 17 residents in the survey sample, Resident #5.The findings include:For Resident #5 (Resident R5), the facility staff failed to maintain the call bell in reach.On the most recent MDS (minimum data set),
an admission assessment, with an ARD (assessment reference date) of 8/24/25, the resident was assessed as being cognitively intact for making daily decisions. Resident R5 was assessed as not having any limitations in range of motion to the upper extremities, dependent on staff for toileting hygiene and requiring substantial to maximal assistance for transfers.On 9/8/2025 at 12:05 p.m., an observation was made of Resident R5
in their room. Resident R5 was observed lying in bed with the call bell observed on the right upper bed rail wrapped around the lower portion of the rail. When asked if they were able to reach their call bell, Resident R5 attempted to locate the call bell and stated that he did not know where it was and could not find it. Resident R5 stated that he did use the call bell to get staff when he needed care and they normally responded in a timely manner.Additional observations of Resident R5's call bell were made on 9/8/2025 at 1:49 p.m. and 2:37 p.m. The call bell was located on the right upper bed rail wrapped around the lower portion of the rail.On 9/9/2025 at 12:36 p.m., an interview was conducted with CNA (certified nursing assistant) #1 who stated that call bells should be placed in reach of all residents. She stated that this was so the resident could call if they needed something. CNA #1 stated that they checked the call bell placement every time they went into the room prior to leaving and when they walked past the rooms. The facility policy, Answering the Call Light revised 8/2020, documented in part, .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.On 9/9/2025 at 1:44 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the findings.No further information was provided prior to exit.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Winchester Health & Rehabilitation
110 Lauck Dr Winchester, VA 22603
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm
to order a different medication, or to say that it was okay for the resident to go without the medication for a certain amount of time.
On 9/9/2025 at 1:44 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the assistant director of nursing were made aware of the findings.
Residents Affected - Some No further information was provided prior to exit.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Winchester Health & Rehabilitation
110 Lauck Dr Winchester, VA 22603
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
own decisions. A review of Resident R1's cognitive assessment dated [DATE REDACTED] revealed he had no cognitive impairment.
A review of Resident R1's clinical record revealed the following progress note dated 9/20/25 at 4:00 p.m.: Resident arrived in a W/C (wheelchair) to floor Little before 1500 (3:00 p.m.). Pleasant and cooperate (sic) with staff.Resident alert and orient (sic) x 3.Resident receives Hemodialysis Tue (Tuesday), Thurs (Thursday), and Saturday.
A review of Resident R1's orders revealed, in part:Insulin Glargine 100 unit/ml (units per milliliter) Inject 15 units subcutaneously every night shift.
Coreg (to treat high blood pressure) 6.25 mg Give 1 tablet by mouth two times a day.
Midodrine (to treat low blood pressure) 5 mg Give 1 tablet by mouth two times a day.
A review of Resident R1's May 2025 MAR (medication administration record) revealed he did not receive insulin as ordered at night on 5/20/25. The insulin was documented as not given, new admit on order in the progress note. This review also revealed he did not receive Coreg or Midodrine medications in the evening on 5/20/25.
A review of the facility's Omnicell list (list of standard medications available at all times for residents) revealed the following medications were available for administration on 5/20/25 at 5:00 p.m.: Insulin Glargine 100 units/ml, Coreg 3.125 mg tablets, and Midodrine 5 mg.
On 9/9/25 at 9:23 a.m., ASM (administrative staff member) #3, the assistant director of nursing, was interviewed. She stated orders for new residents are placed in the electronic medical record and directly transmitted to the pharmacy. The pharmacy delivers them as soon as possible. She added: We can also have them stat delivered. She explained the facility has an Omnicell system that contains many standard medications, but not all. The nurse should check the Omnicell before determining that a medication is unavailable. She stated if there is a medication ordered that the facility is not able to obtain, the facility staff will ask the family members to bring in the medication from home. She stated the physician should be notified if a medication is unavailable for administration. The physician should have the opportunity to order
a different medication, or to say that it is okay for the resident to go without the medication for a certain amount of time.
On 9/9/25 at 1:45 p.m., ASM #1, the administrator and ASM #2, the director of nursing, were informed of
these concerns.
No additional information was provided prior to exit.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Winchester Health & Rehabilitation
110 Lauck Dr Winchester, VA 22603
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
Federal health inspectors cited WINCHESTER HEALTH & REHABILITATION in WINCHESTER, VA for a deficiency under regulatory tag F-F0755 during a complaint investigation conducted on 2025-09-11.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 4 deficiencies cited during this inspection of WINCHESTER HEALTH & REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-13.
WINCHESTER HEALTH & REHABILITATION in WINCHESTER, VA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WINCHESTER, VA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WINCHESTER HEALTH & REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.