Cycle 1
Health 2023-03-23 · Fire 2023-03-23
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Winchester, VA
Shenandoah Valley Westminster Canterbury
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
300 Westminster Canterbury Dr, Winchester, VA
(540) 665-0156
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-01-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.30
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.22
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.78
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
5.78
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
440
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.81
Composite VBP score used to determine payment impact.
Payment multiplier
1.0223
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.52
Baseline 19.91% · Performance 19.80% · Measure score 3.52 · Achievement 3.52 · Improvement 0
Healthcare-associated infections
4.94
Baseline 5.03% · Performance 6.36% · Measure score 4.94 · Achievement 4.94 · Improvement 0
Total nurse turnover
9.46
Baseline 36.11% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 9
Adjusted total nurse staffing
10
Baseline 5.76 hours · Performance 6.04 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 80 · Observed rate 8.75% · Lower 95% interval 7.05% |
| Discharge to community | 57.41% |
50.57%
6.8 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 59.7% · Lower 95% interval 47.66% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 38 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 85.29% |
53.69%
31.6 pts better
|
Numerator 29 · Denominator 34 |
| Discharge mobility score | 61.76% |
50.94%
10.8 pts better
|
Numerator 21 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 37 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.36% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 2.17% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 3.74% |
8.2%
4.5 pts worse
|
Numerator 14 · Denominator 374 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 388 |
| Discharge function score | 79.41% |
56.45%
23 pts better
|
Numerator 27 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 65% |
25.2%
39.8 pts better
|
Numerator 13 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.4
0.7 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.8% · Q3 2.6% · Q4 2.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.7%
2.4 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.2% · Q3 3.4% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
20.2%
1.8 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 18.8% · Q3 16.7% · Q4 21.4% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
15.0%
7.7 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 8.3% · Q3 8.7% · Q4 4.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.8% |
17.5%
19.3 pts worse
|
16.3%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 35.9% · 4Q avg 36.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.7% |
15.7%
15 pts worse
|
14.9%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 51.7% · Q3 31.0% · Q4 28.0% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.6%
1.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
22.2%
5.3 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 24.9% · Q3 37.1% · Q4 17.2% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.2%
2.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.9% · Q3 5.5% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
74.6%
25.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
11.7%
2.7 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
73.6%
24.8 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.9% |
22.0%
3.1 pts better
|
23.9%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 16.7% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-23 · Fire 2021-09-23
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-02-21 · Fire 2020-02-21
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-23
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-13
C · Minimal harm
2023-03-23
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-05-05
D · Potential for more than minimal harm
2021-09-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-11-04
D · Potential for more than minimal harm
2021-09-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-11-04
E · Potential for more than minimal harm
2020-02-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-09-17
D · Potential for more than minimal harm
2020-02-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-09-17
D · Potential for more than minimal harm
2020-02-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-09-17
D · Potential for more than minimal harm
2020-02-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2020-09-17
D · Potential for more than minimal harm
2020-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-09-17
D · Potential for more than minimal harm
2020-02-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-09-17
D · Potential for more than minimal harm
2020-02-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-09-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-03-23
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-23
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-03-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-05
E · Potential for more than minimal harm
2021-09-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-23
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-10-22
D · Potential for more than minimal harm
2021-09-23
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2021-10-22
E · Potential for more than minimal harm
2020-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-04
D · Potential for more than minimal harm
2020-02-21
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2020-04-04
D · Potential for more than minimal harm
2020-02-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-04-04
D · Potential for more than minimal harm
2020-02-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-04-04
D · Potential for more than minimal harm
2020-02-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-04-04
D · Potential for more than minimal harm
2020-02-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-04-04
D · Potential for more than minimal harm
2020-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-04-04
C · Minimal harm
2020-02-21
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2020-04-04
C · Minimal harm
2020-02-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2020-04-04
Penalties and ownership
What sits behind the stars
Ownership
Harris, Michelle
Operational/Managerial Control · Individual
Harris, Michelle
Corporate Director · Individual
Heishmann, Andrew
Operational/Managerial Control · Individual
Heishmann, Andrew
Corporate Director · Individual
Patterson, Paige
Operational/Managerial Control · Individual
Shiley, Gloria
Operational/Managerial Control · Individual
Shiley, Gloria
Corporate Officer · Individual
Wernecke, Duane
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Winchester Health & Rehabilitation
Winchester, VA
2-star overall rating with 1-star inspections with 31 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Village At Orchard Ridge
Winchester, VA
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Evergreen Health And Rehabilitation Center
Winchester, VA
2-star overall rating with 2-star inspections with $8,190 in total fines with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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