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Public Record

Windsor Grove Health and Rehabilitation

Nursing HomeWindsor, VACMS 495347
62 citations on record

Operated by Avardis Health

From CMS

Facility profile

CMS overall rating
1 / 5

*CMS Five-Star

Certified beds
114

*CMS

Avg. residents per day
109.2

*CMS

Inspection record

On record from CMS

Health citations
62

*CMS

Fire safety findings
19

*CMS

Inspections on file
7

*CMS

Last inspection
2025-05-01

*CMS

Citations

62 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

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.

  • 0558Generalpotential for harm

    Reasonably accommodate the needs and preferences of each resident.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0678Generalpotential for harm

    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0685Generalpotential for harm

    Assist a resident in gaining access to vision and hearing services.

  • 0687Generalpotential for harm

    Provide appropriate foot care.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0725Generalpotential for harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0730Generalpotential for harm

    Observe each nurse aide's job performance and give regular training.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0761Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0925Generalpotential for harm

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  • 0691Generalpotential for harm

    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

  • 0925Generalpotential for harm

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  • 0919Generalpotential for harm

    Make sure that a working call system is available in each resident's bathroom and bathing area.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0584Generalpotential for harm

    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.

  • 0623Generalpotential for harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0550Generalpotential for harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0567Generalpotential for harm

    Honor the resident's right to manage his or her financial affairs.

  • 0574Generalpotential for harm

    The resident has the right to receive notices in a format and a language he or she understands.

  • 0602Generalpotential for harm

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0622Generalpotential for harm

    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.

  • 0625Generalpotential for harm

    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.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0690Generalpotential for harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0758Generalpotential for harm

    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.

  • 0761Generalpotential for harm

    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.

  • 0773Generalpotential for harm

    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

  • 0775Generalpotential for harm

    Keep complete, dated laboratory records in the resident's record.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0641Generalpotential for harm

    Ensure each resident receives an accurate assessment.

  • 0641Generalpotential for harm

    Ensure each resident receives an accurate assessment.

  • 0580Generalpotential for harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0582Generalpotential for harm

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0583Generalpotential for harm

    Keep residents' personal and medical records private and confidential.

  • 0584Generalpotential for harm

    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.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0607Generalpotential for harm

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0622Generalpotential for harm

    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.

  • 0625Generalpotential for harm

    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.

  • 0656Generalpotential for harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0692Generalpotential for harm

    Provide enough food/fluids to maintain a resident's health.

  • 0727Generalpotential for harm

    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.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0761Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0610Generalpotential for harm

    Respond appropriately to all alleged violations.

Inspection history

Every health inspection on record

Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.

Ownership

Avardis Health

38nursing homes nationwide, in CMS records

See the full ownership footprint

FAQ

Questions and answers

What is Windsor Grove Health and Rehabilitation?
Windsor Grove Health and Rehabilitation is a Medicare- and Medicaid-certified nursing home in Windsor, VA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 495347.
What is the CMS rating for Windsor Grove Health and Rehabilitation?
Windsor Grove Health and Rehabilitation has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Windsor Grove Health and Rehabilitation have?
Windsor Grove Health and Rehabilitation is certified for 114 beds. It serves an average of 109.2 residents per day.
How many citations does Windsor Grove Health and Rehabilitation have?
Windsor Grove Health and Rehabilitation has 62 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Windsor Grove Health and Rehabilitation last inspected?
Windsor Grove Health and Rehabilitation was last inspected on May 1, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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