Starfile / Virginia

Windsor Grove Health and Rehabilitation

23352 COURTHOUSE HIGHWAY, WINDSOR, VA 23487 · CCN 495347

Inspection history vs Virginia & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$0

Number of fines

0

Number of penalties

0

Payment denials

0

Chain

Chain

AVARDIS HEALTH

Facilities in chain

14

Chain avg overall

2.10 / 5

Inspection citations (62)

1. DF0558Reasonably accommodate the needs and preferences of each resident.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

2. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

3. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

4. DF0610Respond appropriately to all alleged violations.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

5. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

6. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

7. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

8. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

9. DF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2025-05-01 · Health · corrected 2025-06-26

   Potential for more than minimal harm

10. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

11. DF0685Assist a resident in gaining access to vision and hearing services.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

12. DF0687Provide appropriate foot care.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

13. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

14. DF0692Provide enough food/fluids to maintain a resident's health.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

15. FF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

16. EF0730Observe each nurse aide's job performance and give regular training.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

17. EF0760Ensure that residents are free from significant medication errors.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

18. DF0761Ensure 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.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

19. DF0880Provide and implement an infection prevention and control program.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

20. DF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2025-05-01 · Health · corrected 2025-06-26

    Potential for more than minimal harm

21. DF0584Honor 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.2024-11-14 · Health · corrected 2025-01-04

    Potential for more than minimal harm

22. DF0691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.2024-11-14 · Health · corrected 2025-01-04

    Potential for more than minimal harm

23. DF0692Provide enough food/fluids to maintain a resident's health.2024-11-14 · Health · corrected 2025-01-04

    Potential for more than minimal harm

24. EF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-11-14 · Health · corrected 2025-01-04

    Potential for more than minimal harm

25. EF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2024-11-14 · Health · corrected 2025-01-04

    Potential for more than minimal harm

26. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

27. DF0567Honor the resident's right to manage his or her financial affairs.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

28. DF0574The resident has the right to receive notices in a format and a language he or she understands.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

29. DF0602Protect each resident from the wrongful use of the resident's belongings or money.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

30. DF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

31. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

32. DF0625Notify 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.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

33. DF0641Ensure each resident receives an accurate assessment.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

34. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2021-03-26 · Health · corrected 2020-07-26

    Potential for more than minimal harm

35. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

36. DF0758Implement 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.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

37. DF0761Ensure 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.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

38. DF0773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

39. DF0775Keep complete, dated laboratory records in the resident's record.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

40. DF0881Implement a program that monitors antibiotic use.2021-03-26 · Health · corrected 2021-05-07

    Potential for more than minimal harm

41. EF0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

42. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

43. DF0582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.2019-06-27 · Health · corrected 2019-02-26

    Potential for more than minimal harm

44. DF0583Keep residents' personal and medical records private and confidential.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

45. DF0584Honor 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.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

46. DF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

47. DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

48. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

49. EF0610Respond appropriately to all alleged violations.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

50. EF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

51. EF0625Notify 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.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

52. DF0641Ensure each resident receives an accurate assessment.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

53. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

54. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

55. EF0658Ensure services provided by the nursing facility meet professional standards of quality.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

56. EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

57. DF0692Provide enough food/fluids to maintain a resident's health.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

58. DF0727Have 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.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

59. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

60. DF0760Ensure that residents are free from significant medication errors.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

61. DF0761Ensure 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.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

62. DF0880Provide and implement an infection prevention and control program.2019-06-27 · Health · corrected 2019-08-06

    Potential for more than minimal harm

Ownership

Other facilities in WINDSOR

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.