Virginia › Isle of Wight County › Windsor
Windsor Grove Health and Rehabilitation
23352 Courthouse Highway, Windsor, VA 23487
Ratings are based on the most recent data available; a facility's ratings may have changed since the last update. The health inspection rating is based on the three most recent standard surveys and complaint investigations. CMS processed this record on 1 Aug 2026. View the Care Compare record.
Certified for 114 beds, Windsor Grove Health and Rehabilitation serves Windsor in Isle of Wight County, Virginia and has taken Medicare and Medicaid residents since 2000.
CMS gives it 2 of 5 stars overall, below the Virginia median of 3; the health inspection rating is 2, staffing 2 and quality measures 4.
Inspectors recorded 62 health deficiencies across the three most recent survey cycles (20, 20, 22 by cycle, most recent first), none at the actual-harm level. That is 54.4 per 100 beds, more than the state median of 34.5.
CMS lists no fines or payment denials against the facility in the period covered.
Reported nurse staffing is 2.7 hours per resident per day (0.4 RN), below the Virginia median of 3.4; nursing staff turnover is 56.3%.
Compared with county, state and nation
| Measure | This facility | Isle of Wight Co. median | Virginia median | US average |
|---|---|---|---|---|
| Overall star rating | 2 | 4 | 3 | 3.0 |
| Health citations, 3 cycles | 62 | 62 | 32 | 28.7 |
| Citations per 100 beds | 54.4 | 54.4 | 34.5 | 26.8 |
| Total nurse hours per resident day | 2.7 | 4.5 | 3.4 | 3.9 |
| RN hours per resident day | 0.4 | 1.0 | 0.5 | 0.7 |
| Nursing staff turnover | 56.3% | 59.6% | 48.3% | 45.8% |
| Fines listed | $0 | $0 | $0 | — |
County and state figures are medians across facilities (2 in the county, 289 in the state); the US column is the CMS national average where CMS publishes one.
Citations by survey cycle
Dark bar: this facility. Grey bar: Virginia average per facility for the same cycle, as published by CMS. Standard health survey dates: 1 May 2025, 26 Mar 2021.
Severity mix: D ×51 E ×10 F ×1
Health deficiencies
Every health citation in the current CMS record (three survey cycles), most recent first. Tag text is the CMS requirement summary, not the inspection narrative.
Scope and severity letters (A–L)
| Survey date | Tag | What the tag requires | Severity | Type | Corrected |
|---|---|---|---|---|---|
| 1 May 2025 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | F | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0730 | Observe each nurse aide's job performance and give regular training. | E | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0760 | Ensure that residents are free from significant medication errors. | E | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0610 | Respond appropriately to all alleged violations. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0678 | 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 | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint investigation | 26 Jun 2025 |
| 1 May 2025 | F0685 | Assist a resident in gaining access to vision and hearing services. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0687 | Provide appropriate foot care. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0692 | Provide enough food/fluids to maintain a resident's health. | D | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0761 | 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 | Standard survey | 26 Jun 2025 |
| 1 May 2025 | F0880 | Provide and implement an infection prevention and control program. | D | Complaint investigation | 26 Jun 2025 |
| 1 May 2025 | F0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | D | Standard survey | 26 Jun 2025 |
| 14 Nov 2024 | F0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. | E | Complaint investigation | 4 Jan 2025 |
| 14 Nov 2024 | F0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | E | Complaint investigation | 4 Jan 2025 |
| 14 Nov 2024 | F0584 | 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 | Complaint investigation | 4 Jan 2025 |
| 14 Nov 2024 | F0691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | D | Complaint investigation | 4 Jan 2025 |
| 14 Nov 2024 | F0692 | Provide enough food/fluids to maintain a resident's health. | D | Complaint investigation | 4 Jan 2025 |
| 26 Mar 2021 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0567 | Honor the resident's right to manage his or her financial affairs. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0574 | The resident has the right to receive notices in a format and a language he or she understands. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0602 | Protect each resident from the wrongful use of the resident's belongings or money. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0622 | 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 | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0625 | 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 | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0641 | Ensure each resident receives an accurate assessment. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard survey | 26 Jul 2020 |
| 26 Mar 2021 | F0690 | 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 | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0758 | 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 | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0761 | 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 | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0775 | Keep complete, dated laboratory records in the resident's record. | D | Standard survey | 7 May 2021 |
| 26 Mar 2021 | F0881 | Implement a program that monitors antibiotic use. | D | Standard survey | 7 May 2021 |
| 27 Jun 2019 | F0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | E | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0610 | Respond appropriately to all alleged violations. | E | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0622 | 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 | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0625 | 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 | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | E | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D | Standard survey | 26 Feb 2019 |
| 27 Jun 2019 | F0583 | Keep residents' personal and medical records private and confidential. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0584 | 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 | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0641 | Ensure each resident receives an accurate assessment. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0692 | Provide enough food/fluids to maintain a resident's health. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0727 | 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 | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0760 | Ensure that residents are free from significant medication errors. | D | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0761 | 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 | Standard survey | 6 Aug 2019 |
| 27 Jun 2019 | F0880 | Provide and implement an infection prevention and control program. | D | Standard survey | 6 Aug 2019 |
Penalties
CMS lists no fines or payment denials for this facility in the period covered.
Staffing
Hours per resident per day as reported through the Payroll-Based Journal; grey bars are the Virginia average. Turnover: nursing staff 56.3%, RNs 55.6%; 0 administrators left in the reporting year.
Quality measures
| Measure | Residents | This facility | Virginia median | US median |
|---|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 14.0% | 13.3% | 12.6% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.2% | 0.2% | 0.3% |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.3% | 1.1% | 0.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.3% | 3.4% | 2.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.6% | 1.0% | 1.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 9.5% | 14.2% | 12.5% |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.3% | 4.2% | 4.2% |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 22.4% | 13.3% | 13.4% |
Four-quarter averages for the measures CMS uses in the quality-measure star rating (2025Q2-2026Q1). Lower is better for every measure listed. Medians are computed across facilities on this site.
Ownership
Ownership type: for-profit, corporation. Legal business name: 23352 Courthouse Highway Opco Llc. Chain: Avardis Health (38 facilities).
| Organisation | Role in the CMS record | Interest | Since |
|---|---|---|---|
| Windsor Parentco LLC | 5% or greater direct ownership interest | 100% | 05/01/2025 |
| Isle of Wight Holdco LLC | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 05/01/2025 |
| Vaop Holdco LLC | 5% or greater indirect ownership interest | NO PERCENTAGE PROVIDED | 05/01/2025 |
| SNF Mgr LLC | Operational/managerial control | NOT APPLICABLE | 05/01/2025 |
| SNF Mgr LLC | Adp of the snf | NOT APPLICABLE | 04/21/2025 |
Only organisations are shown. CMS also records individual owners, officers and managing employees; this site does not publish people's names.
Other nursing homes in Isle of Wight County
| Facility | City | Beds | Overall | Health | Staffing | Citations | Per 100 beds | Fines | Last survey |
|---|---|---|---|---|---|---|---|---|---|
| Riverside Lifelong Health & Rehab Smithfield | Smithfield | 34 | 4 | 4 | 4 | 17 | 50.0 | — | 12 Apr 2024 |
All 2 facilities in Isle of Wight County
Questions and answers
How many deficiencies has Windsor Grove Health and Rehabilitation been cited for?
62 health deficiencies across the three most recent survey cycles, 0 at the actual-harm or immediate-jeopardy level. The Virginia median is 32 per facility.
Has Windsor Grove Health and Rehabilitation been fined?
CMS lists no fines against the facility in the period covered.
How does staffing at Windsor Grove Health and Rehabilitation compare?
Reported total nurse staffing is 2.7 hours per resident per day against a Virginia median of 3.4 and a national average of 3.9.
Who operates Windsor Grove Health and Rehabilitation?
It is part of the Avardis Health chain. Ownership type is for-profit, corporation. Organisations in the CMS ownership record include Windsor Parentco LLC, Isle of Wight Holdco LLC and Vaop Holdco LLC. Individual owners and managers are not listed on this site.
When was Windsor Grove Health and Rehabilitation last inspected?
The most recent survey or investigation in the CMS record is dated 1 May 2025; the most recent standard health survey was 1 May 2025.
Where does this data come from?
All figures are from the Centers for Medicare & Medicaid Services Care Compare datasets (provider information, health deficiencies, penalties, ownership and quality measures), processed 1 Aug 2026. Ratings and citations may change; the Care Compare record is authoritative.
Provenance
Source: Centers for Medicare & Medicaid Services, Care Compare nursing home datasets (provider information, health deficiencies, penalties, ownership, MDS quality measures, state and national averages), public domain, processed by CMS on 1 Aug 2026. Facility record: Care Compare. Errors in processing are corrected at the next daily build; see corrections.