Windsor Grove Health and Rehabilitation

23352 COURTHOUSE HIGHWAY
WINDSOR, VA, 23487
7572424770
CCN: 495347
1
Overall
2
Health
1
Staffing
4
Quality
ChainAVARDIS HEALTH
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
WINDSOR PARENTCO LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
ISLE OF WIGHT HOLDCO LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
NU C II IRREVOCABLE TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
NU C IRREVOCABLE TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SNF CARE CENTERS LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
VAOP HOLDCO LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
ZENITH HOLDCO II LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
ZENITH HOLDCO LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SNF MGR LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
COLBURN, JEFFREYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
HOBACK, TIFFANYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
JONES, TEQUILLAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MORGAN, DANIELOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
UPTEGROW, RACHELLEOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
WHITLEY, NAKIAOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Health Deficiencies (62)
2025-05-01 · Health
D
F925 · Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F761 · Pharmacy Service Deficiencies
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.
E
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
E
F730 · Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
F
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F687 · Quality of Life and Care Deficiencies
Provide appropriate foot care.
D
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F678 · Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-11-14 · Health
E
F925 · Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
E
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F691 · Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
D
F584 · Resident Rights Deficiencies
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.
2021-03-26 · Health
D
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
D
F775 · Administration Deficiencies
Keep complete, dated laboratory records in the resident's record.
D
F773 · Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
D
F761 · Pharmacy Service Deficiencies
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.
D
F758 · Pharmacy Service Deficiencies
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.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F625 · Resident Rights Deficiencies
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.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F622 · Resident Rights Deficiencies
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.
D
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
D
F574 · Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
D
F567 · Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2019-06-27 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F761 · Pharmacy Service Deficiencies
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.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F727 · Nursing and Physician Services Deficiencies
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.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
E
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
E
F625 · Resident Rights Deficiencies
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.
E
F622 · Resident Rights Deficiencies
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.
E
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
D
F584 · Resident Rights Deficiencies
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.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
D
F582 · Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
E
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
2.61
3.68
RN Hrs/Resident/Day
0.29
0.54
LPN Hrs/Resident/Day
0.74
0.81
CNA Hrs/Resident/Day
1.57
2.33
PT Hrs/Resident/Day
0.02
0.12
Data as of 2026-03-01