Windsor Grove Health and Rehabilitation
Windsor Grove Health and Rehabilitation is a 114-bed nursing home in WINDSOR, Virginia, certified for Medicare and Medicaid since 2000-08-01, averaging 107.2 residents a day.
Has Windsor Grove Health and Rehabilitation been cited for violations?
CMS lists 62 health-inspection deficiencies for Windsor Grove Health and Rehabilitation since 2019-06-27, 25 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is F; the most recent health inspection was 2025-05-01.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2025-05-01 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F |
| 2025-05-01 | F0730, F0760 | Observe each nurse aide's job performance and give regular training. / Ensure that residents are free from significant medication errors. | E |
| 2025-05-01 | F0558, F0580, F0609, F0610, F0656, F0657, F0658, F0677, F0678, F0684, F0685, F0687, F0689, F0692, F0761, F0880, F0925 | Reasonably accommodate the needs and preferences of each resident. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / 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 appropriate treatment and care according to orders, resident’s preferences and goals. / Assist a resident in gaining access to vision and hearing services. / Provide appropriate foot care. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide enough food/fluids to maintain a resident's health. / 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. / Provide and implement an infection prevention and control program. / Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | D |
| 2024-11-14 | F0919, F0925 | 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. | E |
| 2024-11-14 | F0584, F0691, F0692 | 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. | D |
| 2021-03-26 | F0550, F0567, F0574, F0602, F0622, F0623, F0625, F0641, F0689, F0690, F0758, F0761, F0773, F0775, F0881 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / 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. / Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. / Keep complete, dated laboratory records in the resident's record. / Implement a program that monitors antibiotic use. | D |
| 2019-06-27 | F0561, F0610, F0622, F0625, F0658, F0684 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / Respond appropriately to all alleged violations. / 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. / 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 services provided by the nursing facility meet professional standards of quality. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E |
| 2019-06-27 | F0580, F0582, F0583, F0584, F0600, F0607, F0609, F0641, F0656, F0657, F0692, F0727, F0755, F0760, F0761, F0880 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / Keep residents' personal and medical records private and confidential. / 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. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Ensure each resident receives an accurate assessment. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide enough food/fluids to maintain a resident's health. / 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. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. / Provide and implement an infection prevention and control program. | D |
How is Windsor Grove Health and Rehabilitation staffed relative to the VA average?
| Measure | This facility | VA average |
|---|---|---|
| Total nurse staffing hours per resident per day | 2.70508 | 3.75779 |
| Total nursing staff turnover (%) | 56.3 | 48.1 |
| Average number of residents per day | 107.2 | 99.5 |
Who owns Windsor Grove Health and Rehabilitation, and what chain is it in?
Windsor Grove Health and Rehabilitation is registered with CMS as For profit - Corporation, operates under the legal business name 23352 COURTHOUSE HIGHWAY OPCO LLC and belongs to the AVARDIS HEALTH chain.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | WINDSOR PARENTCO LLC | since 05/01/2025 |
| 5% OR GREATER INDIRECT OWNERSHIP INTEREST | ISLE OF WIGHT HOLDCO LLC, VAOP HOLDCO LLC | since 05/01/2025 |
| MANAGING CONTROL - GOVERNING BODY | HOBACK, TIFFANY, MORGAN, DANIEL | since 05/01/2025 |
| OPERATIONAL/MANAGERIAL CONTROL | SNF MGR LLC, COLBURN, JEFFREY, HOBACK, TIFFANY, JONES, TEQUILLA, MORGAN, DANIEL, UPTEGROW, RACHELLE, WHITLEY, NAKIA | since 05/01/2025 |
| ADP OF THE SNF | SNF MGR LLC, COLBURN, JEFFREY, HOBACK, TIFFANY, JONES, TEQUILLA, MORGAN, DANIEL, UPTEGROW, RACHELLE, WHITLEY, NAKIA | since 03/06/1972 |
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