Cycle 1
Health 2023-04-06 · Fire 2023-04-06
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Williamsburg, VA
Windsormeade Of Williamsburg
5-star overall rating with 5-star inspections with 3 recent health deficiencies
3900 Windsor Hall Drive, Williamsburg, VA
(757) 941-3600
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
22
Certified beds
Average residents
19
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-03-03
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
2.15
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
5.72
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.46
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.69
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
1.30
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
2.24
CMS adjusted RN staffing hours
Adjusted total hours
5.96
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,703
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9960
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.86
Baseline 18.65% · Performance 19.65% · Measure score 3.86 · Achievement 3.86 · Improvement 0
Healthcare-associated infections
0
Baseline 4.96% · Performance 8.65% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.06
Baseline 22.73% · Performance 26.67% · Measure score 9.06 · Achievement 9.06 · Improvement 0
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 | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 9.04% · Lower 95% interval 7.99% |
| Discharge to community | 70.09% |
50.57%
19.5 pts better
|
Better than the National Rate · Eligible stays 201 · Observed rate 72.14% · Lower 95% interval 63.43% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 132 · Denominator 132 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 132 |
| Discharge self-care score | 60.34% |
53.69%
6.7 pts better
|
Numerator 70 · Denominator 116 |
| Discharge mobility score | 37.07% |
50.94%
13.9 pts worse
|
Numerator 43 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 132 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.65% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 8.33% · Lower 95% interval 5.45% |
| Staff COVID-19 vaccination coverage | 23.81% |
8.2%
15.6 pts better
|
Numerator 15 · Denominator 63 |
| Staff flu vaccination coverage | 88.16% |
42%
46.2 pts better
|
Numerator 67 · Denominator 76 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 58 · Denominator 116 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 79 · Denominator 79 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 61.04% |
25.2%
35.8 pts better
|
Numerator 47 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 22.2% |
3.6%
18.6 pts worse
|
3.3%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.2% · 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 | 5.0% |
20.2%
15.2 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% |
| 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 | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
1.6%
2.2 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.6% |
22.2%
7.4 pts worse
|
19.8%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.2%
2.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
74.6%
14.2 pts better
|
81.7%
7.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.7% · Q2 92.5% · Q3 90.4% · Q4 85.0% · 4Q avg 88.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
11.7%
0.6 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 9.5% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.8% |
73.6%
23.2 pts better
|
79.7%
17.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
22.0%
2.3 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 15.5% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-19 · Fire 2022-05-19
2 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-12-04 · Fire 2020-12-04
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.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-04-06
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 2023-05-12
D · Potential for more than minimal harm
2023-04-06
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-06
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-05-12
E · Potential for more than minimal harm
2022-05-19
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-05-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-07-01
E · Potential for more than minimal harm
2020-12-04
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-01-15
C · Minimal harm
2020-12-04
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2021-01-15
B · Minimal harm
2020-12-04
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 2021-01-15
B · Minimal harm
2020-12-04
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 2021-01-15
Penalties and ownership
What sits behind the stars
Ownership
Virginia United Methodist Homes Of Williamsburg, Inc.
5% Or Greater Direct Ownership Interest · Organization
Virginia United Methodist Homes, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Alsup, Philip
Corporate Director · Individual
Bruny, Kevin
Corporate Director · Individual
Bryant, Harvey
Corporate Director · Individual
Cauffman, Shirley
Corporate Director · Individual
Coleman, Henry
Corporate Director · Individual
Green, James
Operational/Managerial Control · Individual
Han, Lisa
Corporate Director · Individual
Henderson, Christopher
Corporate Director · Individual
Henderson, Christopher
Corporate Officer · Individual
Hetherington, Jason
Corporate Director · Individual
Hornbeck, Jane
Corporate Director · Individual
Jones, Steven
Corporate Director · Individual
Lakkis, Rouba
Operational/Managerial Control · Individual
Netting, Florence
Corporate Director · Individual
Nimon, Daniel
Operational/Managerial Control · Individual
Nimon, Daniel
Corporate Officer · Individual
Nowell, Kesha
Operational/Managerial Control · Individual
Parikh, Pranav
Operational/Managerial Control · Individual
Salminen, Kevin
Operational/Managerial Control · Individual
Salminen, Kevin
Corporate Officer · Individual
Staskiel, Andrea
Operational/Managerial Control · Individual
Williams, Lisa
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Williamsburg Post Acute & Rehabilitation
Williamsburg, VA
3-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Riverside Lifelong Health & Rehabilitation Patri
Williamsburg, VA
4-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Woodhaven Hall At Williamsburg Landing
Williamsburg, VA
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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