Inspection visit
Fire Safety inspection
Citations
17 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0741GeneralS&S Dpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0761GeneralS&S Dpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0918GeneralS&S Dpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0921GeneralS&S Dpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0004GeneralS&S Dpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Dpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0015GeneralS&S Dpotential for harm
Address subsistence needs for staff and patients.
- 0024GeneralS&S Dpotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Dpotential for harm
Establish roles under a Waiver declared by secretary.
- 0032GeneralS&S Dpotential for harm
Provide primary/alternate means for communication.
- 0034GeneralS&S Dpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Dpotential for harm
Provide family notifications of emergency plan.
- 0037GeneralS&S Dpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Dpotential for harm
Conduct testing and exercise requirements.
- 0232GeneralS&S Dpotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
FAQ · About this visit
Common questions about this visit
What happened during the July 30, 2025 survey of ELK RIVER HEALTH & NURSING CENTER OF WINCHESTER?
This was a inspection survey of ELK RIVER HEALTH & NURSING CENTER OF WINCHESTER on July 30, 2025. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELK RIVER HEALTH & NURSING CENTER OF WINCHESTER on July 30, 2025?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguish..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.