Winchester Health & Rehabilitation
WINCHESTER HEALTH & REHABILITATION in WINCHESTER, VA — inspection on September 11, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
accessible to the resident for one of 17 residents in the survey sample, Resident #5.The findings
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. 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 R5 in their room. 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, R5 attempted to locate the call bell and stated that he did not know where it was and could not find it. 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 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.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
495389 09/11/2025
Winchester Health & Rehabilitation 110 Lauck Dr Winchester, VA 22603
without the medication for a certain amount of time.
assistant director of nursing were made aware of the findings.
No further information was provided prior to exit.
495389 09/11/2025
Winchester Health & Rehabilitation 110 Lauck Dr Winchester, VA 22603
make his own decisions. A review of R1's cognitive assessment dated [DATE] revealed he had no
A review of R1's clinical record revealed the following progress note dated 9/20/25 at 4:00 p.m.:
(sic) with staff.Resident alert and orient (sic) x 3.Resident receives Hemodialysis Tue (Tuesday), Thurs (Thursday), and Saturday.
A review of 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 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.
495389 09/11/2025
Winchester Health & Rehabilitation 110 Lauck Dr Winchester, VA 22603
restless legs syndrome.
This information was obtained from the website:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.