Winchester Health & Rehabilitation
Winchester, Virginia · CCN 495389
13 surveys since 2011, and no finding has been recorded at harm level.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 146
- Surveys
- 13
- Harm or worse
- 0
- Immediate jeopardy
- 0
No finding on record has been cited at harm level or above.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 60
- Ownership
- For profit - Corporation
- Chain
- HILL VALLEY HEALTHCARE
- County
- Frederick
- Medicare-certified since
- 2006
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 2
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 33 for-profit facilities with fewer than 66 beds in Virginia.
Last survey on record
Sep 11, 2025
424 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.35 | 3.46 |
| Registered-nurse hours per resident day | 0.74 | — |
| Annual nurse turnover | 64.0% | 55.1% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D4766.2% | E2028.2% | F— |
| No harm, potential for minimal | A— | B11.4% | C34.2% |
Most frequently cited here
In CMS’s current monthly file.
- F6233×
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- F6253×
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- F6563×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6573×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F6843×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
In the surveyor’s words
From the most serious findings on record at Winchester Health & Rehabilitation, in the surveyor’s own words.
- No harm, potential for more than minimal, patternF580Sep 11, 2025
Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of medications that were unavailable for administration for three of 17 residents in the survey sample, Residents #1, #3, and #12.The findings include:1. For Resident #1 (R1), the facility staff failed to notify the physician of medications unavailable for administration on 5/20/25. A review of 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. […]
- No harm, potential for more than minimal, patternF755Sep 11, 2025
Based on clinical record review, staff interview and facility document review, facility staff failed to provide medications as ordered for four of 17 residents in the survey sample, Residents #3 (R3), R11, R1 and R12. The findings include:1. For R3, facility staff failed to administer Panoxyl (1) according to the physician's orders. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 08/07/2024, R3 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The physician's order for R3 documented in part, Panoxyl External Liquid (Benzoyl Peroxide) Apply to body topically one time a day for acne. Order date: 9/20/2024. […]
- No harm, potential for more than minimal, patternF677Apr 12, 2023
Based on staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for two of 32 residents in the survey sample, Residents #263 and #262. The findings include: 1.a. For Resident #263 (R263), the facility staff failed to assist the resident with bathing/showers on multiple dates May 2022 through July 2022. R263's comprehensive care plan dated 10/28/21 documented, (R263) has an ADL self-care performance deficit r/t (related to) Activity Intolerance, Fatigue, Impaired balance, Limited Mobility, Musculoskeletal impairment and Chronic pain. […]
- No harm, potential for more than minimal, patternF686Apr 12, 2023
Based on staff interview and clinical record review, it was determined the facility staff failed to administer treatments to a pressure injury for one of 32 residents in the survey sample, Resident #14. The findings include: A. For Resident #14 (R14), the facility staff failed to evidence the administration of a wound vacuum for a sacral pressure injury. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. […]
- No harm, potential for more than minimal, patternF691Apr 12, 2023
Based on staff interview and clinical record review, it was determined the facility staff failed to provide colostomy care for two of 32 residents in the survey sample, Residents #110 and #310. The findings include: Colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. (1) 1. For Resident #110, the facility staff failed to evidence that colostomy care was completed. […]
Read 20 findings in full →The most serious and the most recent: 20 of 146 on record.
Every survey on record
FindingsAt actual harm or above
- Sep 11, 2025Complaint4 findings
- Apr 12, 2023Standard and complaint30 findings
- Sep 9, 2021Standard and complaint25 findings
- Jun 17, 2020Infection control1 finding
- Jan 9, 2020Standard15 findings
- Oct 12, 2018Standard and complaint13 findings
- Aug 3, 2017Standard and complaint10 findings
- Jul 28, 2016Standard11 findings
Show the 5 earlier surveys
- Jul 23, 2015Standard and complaint13 findings
- Aug 7, 2014Standard6 findings
- Jul 19, 2013—8 findings
- Aug 24, 2012—7 findings
- Jul 29, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction