Cycle 1
Health 2024-03-06 · Fire 2024-03-06
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Winchester, VA
The Village At Orchard Ridge
5-star overall rating with 4-star inspections with 4 recent health deficiencies
100 Procession Way, Winchester, VA
(540) 431-2800
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
19
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
National Lutheran Communities & Services
Operator or chain grouping
Approved since
2014-07-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 4 overall / 3 health / 4 staffing / 5 quality stars
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
1.43
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
4.46
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
4.17
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,700
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.33% · Performance 21.80% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.62
Baseline 5.29% · Performance 5.86% · Measure score 6.62 · Achievement 6.62 · Improvement 0
Total nurse turnover
2.08
Baseline 70.37% · Performance 58.62% · Measure score 2.08 · Achievement 1.24 · Improvement 2.08
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.44% |
10.72%
2.3 pts better
|
No Different than the National Rate · Eligible stays 160 · Observed rate 3.13% · Lower 95% interval 5.85% |
| Discharge to community | 61.11% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 150 · Observed rate 64.67% · Lower 95% interval 54.99% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.5% |
95.27%
0.2 pts better
|
Numerator 106 · Denominator 111 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 111 |
| Discharge self-care score | 69.23% |
53.69%
15.5 pts better
|
Numerator 63 · Denominator 91 |
| Discharge mobility score | 45.05% |
50.94%
5.9 pts worse
|
Numerator 41 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 0.9% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 111 · Adjusted rate 1.14% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 1.82% · Lower 95% interval 2.84% |
| Staff COVID-19 vaccination coverage | 4.71% |
8.2%
3.5 pts worse
|
Numerator 4 · Denominator 85 |
| Staff flu vaccination coverage | 97.89% |
42%
55.9 pts better
|
Numerator 93 · Denominator 95 |
| Discharge function score | 74.73% |
56.45%
18.3 pts better
|
Numerator 68 · Denominator 91 |
| Transfer of health information to provider | 97.06% |
95.95%
1.1 pts better
|
Numerator 33 · Denominator 34 |
| Transfer of health information to patient | 98.51% |
96.28%
2.2 pts better
|
Numerator 66 · Denominator 67 |
| Resident COVID-19 vaccinations up to date | 22.03% |
25.2%
3.2 pts worse
|
Numerator 13 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
91.2%
8.3 pts worse
|
93.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 82.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.0% |
20.2%
14.8 pts worse
|
19.6%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.0% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.5%
1.1 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.6%
1.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
22.2%
3.1 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 13.0% |
5.2%
7.8 pts worse
|
5.1%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.0% |
74.6%
6.6 pts worse
|
81.7%
13.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.5% · Q2 65.4% · Q3 79.7% · Q4 74.0% · 4Q avg 68.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
11.7%
2.2 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 12.0% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.2% |
73.6%
17.4 pts worse
|
79.7%
23.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
22.0%
3.4 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 13.0% · Expected 16.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-01 · Fire 2022-06-01
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-02-25 · Fire 2021-02-25
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-03-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-06
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 2024-04-01
D · Potential for more than minimal harm
2024-03-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-01
Penalties and ownership
What sits behind the stars
Ownership
National Lutheran Inc
5% Or Greater Direct Ownership Interest · Organization
Ault, Jared
Operational/Managerial Control · Individual
Blakemore, Victoria
Corporate Director · Individual
Casner, Donna
Corporate Officer · Individual
Combs, Allison
Operational/Managerial Control · Individual
Combs, Allison
Corporate Director · Individual
Coulter, Bonnie
Operational/Managerial Control · Individual
Cruz, Medardo
Operational/Managerial Control · Individual
Custer, William
Operational/Managerial Control · Individual
Gwinn, Lauren
Operational/Managerial Control · Individual
Hearn, Garri Ann
Operational/Managerial Control · Individual
Hollis, Michelle
Operational/Managerial Control · Individual
Isham, Sarah
Operational/Managerial Control · Individual
Loy, Shannon
Operational/Managerial Control · Individual
Mason, Susan
Operational/Managerial Control · Individual
Midolo, John
Corporate Director · Individual
Nastasi, Steven
Operational/Managerial Control · Individual
Nastasi, Steven
Corporate Director · Individual
National Lutheran Inc
Operational/Managerial Control · Organization
Palomo, Mary
Operational/Managerial Control · Individual
Patterson, Elizabeth
Operational/Managerial Control · Individual
Portalanza, Joanne
Operational/Managerial Control · Individual
Radigan, Erin
Operational/Managerial Control · Individual
Rosamond, Lori
Operational/Managerial Control · Individual
Rutz, Melissa
Operational/Managerial Control · Individual
Wagoner, Craig
Corporate Officer · Individual
Walters, Cynthia
Corporate Officer · Individual
Wood, Melissa
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Shenandoah Valley Westminster Canterbury
Winchester, VA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
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
#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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