Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health & Rehabilitation during CMS and state inspections, most recent first.
Facility staff did not notify physicians when several residents missed doses of ordered medications due to unavailability. In each case, the medication administration records and progress notes showed that medications were not given, but there was no documentation of physician notification, despite facility policy requiring it. The affected residents had complex medical needs and were prescribed medications for conditions such as diabetes, hypertension, neuropathy, bipolar disorder, and pulmonary hypertension.
Facility staff failed to administer prescribed medications to four residents due to unavailability and delays in pharmacy delivery, with documentation showing missed doses, lack of timely physician notification, and ineffective use of available medication stock in the Omnicell system.
A resident who was cognitively intact and required assistance for transfers and toileting was observed multiple times with the call bell out of reach, wrapped around the lower portion of the bed rail. The resident could not locate or access the call bell when asked, despite facility policy and staff statements that call bells should always be within easy reach.
Staff failed to assess and document a resident's ongoing skin rash despite a physician's order for topical treatment, and did not administer prescribed medications to another resident even though the medications were available. An LPN confirmed that abnormal skin conditions should be documented, and the assistant director of nursing stated that staff should check medication availability and notify the physician if medications cannot be given, but these procedures were not followed.
Failure to Notify Physician of Unavailable Medications
Penalty
Summary
Facility staff failed to notify physicians when ordered medications were unavailable for administration to three residents. For one resident, multiple medications including insulin, antihypertensives, and others were not administered as ordered on a specific evening, and there was no evidence in the clinical record that the physician was informed of the missed doses. The resident had recently arrived, had multiple chronic conditions, and was scheduled for hemodialysis, but the lack of medication administration and physician notification was documented in the medication administration record and progress notes. Another resident did not receive several prescribed medications, including an antifungal, an antipsychotic, and an inhaled medication, on two consecutive days due to unavailability. The electronic medication administration record and nurse's notes indicated the medications were pending delivery or unavailable, but there was no documentation that the physician was notified of the missed doses. The resident had diagnoses including bipolar disorder, pulmonary hypertension, and muscle weakness. A third resident did not receive prescribed Gabapentin for neuropathy over multiple scheduled doses, as the medication was on order from the pharmacy. Progress notes indicated the medication was not available, but again, there was no evidence that the physician or nurse practitioner was notified. Interviews with administrative staff confirmed that the facility's policy requires physician notification when medications are unavailable, but this was not documented in these cases.
Failure to Provide Medications as Ordered Due to Unavailability and Delayed Pharmacy Delivery
Penalty
Summary
Facility staff failed to provide medications as ordered for four residents, resulting in missed doses and lack of timely administration. For one resident, Panoxyl (benzoyl peroxide) was ordered to be applied daily for acne, but the medication was only administered a fraction of the required times over a period of weeks. Documentation showed repeated notes of the medication being pending, pharmacy being notified, and awaiting delivery, with the Omnicell system lacking the medication. The facility's policy required staff to notify the physician and seek alternative orders if a medication was unavailable, but there was no evidence that this was consistently done. Another resident did not receive Clotrimazole, Aripiprazole, and Fluticasone-Salmeterol as ordered, with the eMAR indicating the medications were not available and pending delivery. The Omnicell system did not have these medications in stock, and there was no documentation that the physician was notified about the unavailability. Similarly, a third resident did not receive multiple medications, including Colesevelam, Lyrica, Senokot, and Sevelamer Carbonate, upon admission, as the medications had not yet been received from the pharmacy. Staff interviews confirmed that while orders are transmitted to the pharmacy and stat delivery is possible, the process was not always effective in ensuring timely medication availability. A fourth resident was not administered Gabapentin as ordered for several scheduled doses, with progress notes indicating the medication was on order from the pharmacy. Although lower-dose Gabapentin was available in the Omnicell, staff did not use it due to the need for a new prescription for the different dosage. Interviews with staff and the facility pharmacist confirmed that procedures for obtaining medications from the pharmacy and using available stock were not always followed, and there was a lack of documentation of physician notification when medications were unavailable.
Call Bell Not Maintained Within Resident Reach
Penalty
Summary
Facility staff failed to maintain a call bell in a position accessible to a resident who was cognitively intact and had no upper extremity limitations. The resident was dependent on staff for toileting hygiene and required substantial to maximal assistance for transfers. During multiple observations, the call bell was found wrapped around the lower portion of the right upper bed rail, out of the resident's reach. When asked, the resident was unable to locate or access the call bell and stated he did not know where it was, although he typically used it to request assistance from staff. Staff interviews confirmed that call bells should be placed within easy reach of all residents, and that staff are expected to check call bell placement before leaving the room and when passing by. Facility policy also requires that the call light be within easy reach when a resident is in bed or confined to a chair. Despite these policies and staff awareness, the call bell was not accessible to the resident during the survey observations.
Failure to Monitor Skin Condition and Administer Medications as Ordered
Penalty
Summary
Facility staff failed to provide appropriate care and services for two residents. For one resident, staff did not assess and monitor a skin rash as required. Although there was a physician's order for topical treatment of acne, the facility's weekly skin observation sheets did not document the presence of acne or a rash over several weeks. An LPN confirmed that abnormal skin conditions should be documented as long as they persist, and acknowledged that the resident was not being properly assessed and monitored when documentation was lacking. Facility policy requires nurses to record changes in a resident's condition, but this was not followed in this case. For another resident, staff failed to administer prescribed medications, including insulin, Coreg, and Midodrine, as ordered by the physician. The resident was alert, oriented, and able to make decisions. On the date in question, the medications were available in the facility's Omnicell system, but were not given. The assistant director of nursing explained that staff are expected to check the Omnicell for medication availability and notify the physician if a medication cannot be administered, but this process was not followed. The failure to administer medications and to notify the physician of their omission was confirmed through record review and staff interview.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shenandoah Valley Westminster Canterbury | 0.5 mi | ★★★★★ | 0 | 0 |
| The Village At Orchard Ridge | 2.4 mi | ★★★★★ | 0 | 0 |
| Evergreen Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Rose Hill Health And Rehab | 10.8 mi | ★★★★★ | 0 | 0 |
| Willow Tree Healthcare Center | 17.7 mi | ★★★★★ | 3 | 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.