Nursing homeActive
Windsor Grove Health and Rehabilitation
23352 Courthouse Highway, Windsor, VA 234877572424770114 certified beds · 107 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
4
since 2019
Deficiencies
62
● 0● 62● 0
Penalties · 3 yrs
—
none on file
Last survey
2025-05-01
Standard
CMS overall
2 / 5
stars as published by CMS
CMS overall 2/5
Health 2
Staffing 2
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Virginia Office of Licensure and Certification · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-05-01 | Standard | 0200 | CMS-2567 (Care Compare) | — |
| 2024-11-14 | Complaint | 050 | CMS-2567 (Care Compare) | — |
| 2021-03-26 | Standard | 0150 | CMS-2567 (Care Compare) | — |
| 2019-06-27 | Standard | 0220 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Virginia Office of Licensure and Certification publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F558
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F580
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F610
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F677
F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F678
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F684
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F685
F687Provide appropriate foot care.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F687
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F689
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F692
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F725
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F730
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F760
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F761
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F880
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-06-26Record 495347-20250501-F925
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-04Record 495347-20241114-F584
F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-04Record 495347-20241114-F691
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-04Record 495347-20241114-F692
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-04Record 495347-20241114-F919
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-04Record 495347-20241114-F925
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F550
F567Honor the resident's right to manage his or her financial affairs.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F567
F574The resident has the right to receive notices in a format and a language he or she understands.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F574
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F602
F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F622
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F623
F625Notify 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F625
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F641
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2020-07-26Record 495347-20210326-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F690
F758Implement 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F758
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F761
F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F773
F775Keep complete, dated laboratory records in the resident's record.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F775
F881Implement a program that monitors antibiotic use.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-07Record 495347-20210326-F881
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F561
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F580
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-02-26Record 495347-20190627-F582
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F583
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F584
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F609
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F610
F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F622
F625Notify 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F625
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F658
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F684
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F692
F727Have 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.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F727
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F755
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F760
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F761
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-08-06Record 495347-20190627-F880
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.37
Facility
Virginia
National
Virginia 0.69 · National 0.69
Total nurse hours per resident day2.71
Facility
Virginia
National
Virginia 3.76 · National 3.86
Weekend total nurse hours2.20
Facility
Virginia
National
Virginia 3.29 · National 3.42
Total nursing staff turnover56%
Facility
Virginia
National
Virginia 48% · National 46%
Registered nurse turnover56%
Facility
Virginia
National
Virginia 48% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Virginia | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 4.3% | 4.7% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 4.3% | 3.6% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 22.4% | 14.2% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.3% | 1.6% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 14.0% | 14.9% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 8.1% | 5.4% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 30.3% | 20.6% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Windsor Parentco LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Isle Of Wight Holdco LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Vaop Holdco LLC Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Colburn, Jeffrey Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Hoback, Tiffany Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Jones, Tequilla Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Morgan, Daniel Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| SNF Mgr LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Uptegrow, Rachelle Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Whitley, Nakia Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Colburn, Jeffrey Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Hoback, Tiffany Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Hoback, Tiffany Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Jones, Tequilla Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Morgan, Daniel Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Morgan, Daniel Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| SNF Mgr LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Uptegrow, Rachelle Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Whitley, Nakia Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Avardis Health — 38 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Virginia.
No county cost figures on file for Isle Of Wight.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Lake Prince Woods, Inc Suffolk | 7.4 mi | 2025-11-26 | 030 |
| Autumn Care Of Suffolk Suffolk | 9.0 mi | 2024-09-18 | 0130 |
| Nans Pointe Rehabilitation And Nursing Suffolk | 10.7 mi | 2026-04-25 | 090 |
| Riverside Lifelong Health & Rehab Smithfield Smithfield | 13.6 mi | 2024-04-12 | 060 |
| Southampton Memorial Hosp Franklin | 13.7 mi | 2023-09-22 | 030 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |