Facility WatchInspection records for every certified US nursing home
Windsor Grove Health and Rehabilitation
23352 Courthouse Highway Windsor, VA 23487 (757) 242-4770
CCN
495347
Certified beds
114
Ownership
For profit - Corporation
Chain
Avardis Health
Nurse staffing
3.28
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.42 hours per resident per day
Nursing staff turnover: 55% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected May 1, 2025
20 citations · from a complaint investigation · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0678No actual harm with potential for more than minimal harm · Isolated
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0685No actual harm with potential for more than minimal harm · Isolated
Assist a resident in gaining access to vision and hearing services.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0687No actual harm with potential for more than minimal harm · Isolated
Provide appropriate foot care.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected June 26, 2025
D
F0925No actual harm with potential for more than minimal harm · Isolated
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected June 26, 2025
E
F0730No actual harm with potential for more than minimal harm · Pattern
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected June 26, 2025
E
F0760No actual harm with potential for more than minimal harm · Pattern
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected June 26, 2025
F
F0725No actual harm with potential for more than minimal harm · Widespread
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected June 26, 2025
Inspected November 14, 2024
5 citations · from a complaint investigation · Health
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected January 4, 2025
D
F0691No actual harm with potential for more than minimal harm · Isolated
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected January 4, 2025
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected January 4, 2025
E
F0919No actual harm with potential for more than minimal harm · Pattern
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected January 4, 2025
E
F0925No actual harm with potential for more than minimal harm · Pattern
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Deficient, Provider has date of correction · corrected January 4, 2025
Inspected March 26, 2021
15 citations · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0567No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to manage his or her financial affairs.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0574No actual harm with potential for more than minimal harm · Isolated
The resident has the right to receive notices in a format and a language he or she understands.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0602No actual harm with potential for more than minimal harm · Isolated
Protect each resident from the wrongful use of the resident's belongings or money.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0622No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0625No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Past Non-Compliance · corrected July 26, 2020
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0773No actual harm with potential for more than minimal harm · Isolated
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0775No actual harm with potential for more than minimal harm · Isolated
Keep complete, dated laboratory records in the resident's record.
Deficient, Provider has date of correction · corrected May 7, 2021
D
F0881No actual harm with potential for more than minimal harm · Isolated
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected May 7, 2021
Inspected June 27, 2019
22 citations · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Past Non-Compliance · corrected February 26, 2019
D
F0583No actual harm with potential for more than minimal harm · Isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0727No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected August 6, 2019
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected August 6, 2019
E
F0561No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Deficient, Provider has date of correction · corrected August 6, 2019
E
F0610No actual harm with potential for more than minimal harm · Pattern
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected August 6, 2019
E
F0622No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected August 6, 2019
E
F0625No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected August 6, 2019
E
F0658No actual harm with potential for more than minimal harm · Pattern
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected August 6, 2019
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 6, 2019
Ownership transfers
Effective
Seller
Buyer
06/01/2025
Windsor Facility Operations, LLC
23352 Courthouse Highway Opco LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.