Federal Nursing-Home Survey Record
Windsor Grove Health and Rehabilitation
Does Windsor Grove Health and Rehabilitation have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Windsor Grove Health and Rehabilitation (CCN 495347), in WINDSOR, VA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 20 deficiencies; the most serious carries scope/severity F on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2025-05-01. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.0
Deficiency timeline — full federal history
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Observe each nurse aide's job performance and give regular training.
Ensure that residents are free from significant medication errors.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Provide and implement an infection prevention and control program.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Reasonably accommodate the needs and preferences of each resident.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide appropriate foot care.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Assist a resident in gaining access to vision and hearing services.
Provide enough food/fluids to maintain a resident's health.
Respond appropriately to all alleged violations.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
40 citations from earlier inspection cycles — historical, not current (expand)
Make sure that a working call system is available in each resident's bathroom and bathing area.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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.
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Provide enough food/fluids to maintain a resident's health.
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Honor the resident's right to manage his or her financial affairs.
The resident has the right to receive notices in a format and a language he or she understands.
Protect each resident from the wrongful use of the resident's belongings or money.
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.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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.
Ensure each resident receives an accurate assessment.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Keep complete, dated laboratory records in the resident's record.
Implement a program that monitors antibiotic use.
Ensure services provided by the nursing facility meet professional standards of quality.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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.
Respond appropriately to all alleged violations.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Keep residents' personal and medical records private and confidential.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that residents are free from significant medication errors.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
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.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure each resident receives an accurate assessment.
Provide and implement an infection prevention and control program.
Provide enough food/fluids to maintain a resident's health.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Document what happened
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