Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WINCHESTER HEALTH & REHABILITATION
WINCHESTER, VA · 60 certified beds · Last Life Safety survey April 12, 2023
CMS Certification Number 495389 · first certified October 2006
Ownership
Operated by HILL VALLEY HEALTHCARE · For profit - Corporation
- Ownership changed December 1, 2022 (change of ownership)to WINCHESTER SNF OPERATIONS LLC from ENVOY OF WINCHESTER, LLC
Position within VA
16 citations — more than 72% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: November 2025 to November 2026. This facility’s last Life Safety survey was April 2023. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about WINCHESTER HEALTH & REHABILITATION
One email when it happens. No account; stop it any time with one click.
1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 16 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 16 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 16 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 9, 2020 | 4 |
| September 9, 2021 | 7 |
| April 12, 2023 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-04-12 |
| E-0037 | Establish staff and initial training requirements. | 2 | 2023-04-12 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2020-01-09 |
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | 1 | 2021-09-09 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2020-01-09 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2020-01-09 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2023-04-12 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-04-12 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 3
- Smoke Deficiencies 3
- Other 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
| Smoke Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 12, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (May 26, 2023) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (June 1, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (June 1, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (June 1, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 1, 2023) |
September 9, 2021 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (October 14, 2021) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (October 14, 2021) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 22, 2021) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (November 22, 2021) |
| K-0252 | Provide at least two remote exits on each floor or fire section of the building. | Deficient, Provider has date of correction (November 22, 2021) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 22, 2021) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 22, 2021) |
January 9, 2020 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 4, 2020) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 4, 2020) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 4, 2020) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 4, 2020) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.