Windsor Grove Health and Rehabilitation
Open-data reference.
Windsor Grove Health and Rehabilitation is a for profit - corporation facility in WINDSOR, VA with 114 certified beds and a 1-star overall CMS rating. The facility has 50 deficiency records on file.
23352 COURTHOUSE HIGHWAY, WINDSOR, VA 23487
Phone: 7572424770
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 495347
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 114
- Residents
- 111
- In Hospital
- No
- County
- Isle Of Wight
- Last Inspection
- May 1, 2025
Staffing Data
- RN Hours
- 0.29 (nat'l avg: 0.68)
- LPN Hours
- 0.74
- CNA Hours
- 1.57
- Total Nursing Hours
- 2.61 (nat'l avg: 3.89)
- PT Hours
- 0.02
- Nursing Turnover
- 49.4%
- RN Turnover
- 72.7%
What the CMS Record Reveals About Windsor Grove Health and Rehabilitation
Windsor Grove Health and Rehabilitation operates 114 certified beds in WINDSOR, VA with approximately 111 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (1★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 2.61 total nursing hours per resident day (national average 3.89), with RN coverage at 0.29 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Windsor Grove Health and Rehabilitation falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 49.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 26, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 26, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Jun 26, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Jun 26, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Jun 26, 2025
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 26, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Jun 26, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 26, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 26, 2025
Provide appropriate foot care.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 26, 2025
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 26, 2025
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 26, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 26, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 26, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 26, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 26, 2025
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 26, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 26, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Jun 26, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Jun 26, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Jan 4, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Category: Environmental Deficiencies
Corrected: Jan 4, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 4, 2025
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 4, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jan 4, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: May 7, 2021
Keep complete, dated laboratory records in the resident's record.
Category: Administration Deficiencies
Corrected: May 7, 2021
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Category: Administration Deficiencies
Corrected: May 7, 2021
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.
Category: Pharmacy Service Deficiencies
Corrected: May 7, 2021
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.
Category: Pharmacy Service Deficiencies
Corrected: May 7, 2021
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: May 7, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 26, 2020
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 7, 2021
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.
Category: Resident Rights Deficiencies
Corrected: May 7, 2021
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: May 7, 2021
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.
Category: Resident Rights Deficiencies
Corrected: May 7, 2021
Protect each resident from the wrongful use of the resident's belongings or money.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: May 7, 2021
The resident has the right to receive notices in a format and a language he or she understands.
Category: Resident Rights Deficiencies
Corrected: May 7, 2021
Honor the resident's right to manage his or her financial affairs.
Category: Resident Rights Deficiencies
Corrected: May 7, 2021
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: May 7, 2021
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 6, 2019
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.
Category: Pharmacy Service Deficiencies
Corrected: Aug 6, 2019
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Aug 6, 2019
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 6, 2019
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.
Category: Nursing and Physician Services Deficiencies
Corrected: Aug 6, 2019
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 6, 2019
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 6, 2019
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 6, 2019
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 6, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 6, 2019
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 12.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 5.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 78.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 61.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 5.6% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 31.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 92.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 49.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 29.0% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 18.8% | Yes |
Penalty History
No penalties on record.
Nearby Nursing Homes in VA
ABINGDON HEALTH CARE LLC
ABINGDON, VA
ALBEMARLE HEALTH & REHABILITATION CENTER
CHARLOTTESVILLE, VA
ALEXANDRIA REHABILITATION AND HEALTHCARE CENTER
ALEXANDRIA, VA
ALLEGHANY HEALTH AND REHAB
CLIFTON FORGE, VA
AMELIA REHABILITATION AND HEALTHCARE CENTER
AMELIA, VA
ANNANDALE HEALTHCARE CENTER
ANNANDALE, VA
Understanding Nursing Home Data
Related Data from Other Sources
Doctors Nearby
Find physicians and specialists in WINDSOR, VA on PlainDoctor
Hospitals Nearby
Hospital quality ratings and safety data for WINDSOR, VA on PlainHospital
Medicare Plans
Compare Medicare plans and coverage options near WINDSOR, VA on PlainMedicare
County Health Data
Health outcomes, access, and quality metrics for Isle Of Wight on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for Windsor Grove Health and Rehabilitation?
What are the staffing levels at Windsor Grove Health and Rehabilitation?
How many beds does Windsor Grove Health and Rehabilitation have?
Does Windsor Grove Health and Rehabilitation have any deficiencies on record?
Has Windsor Grove Health and Rehabilitation received any fines or penalties?
Who owns Windsor Grove Health and Rehabilitation?
When was Windsor Grove Health and Rehabilitation last inspected?
What quality measures are tracked for Windsor Grove Health and Rehabilitation?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.