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Nursing HomeMedicaid Investigative

Windsor Grove Health and Rehabilitation

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

23352 Courthouse Highway, Windsor, VA 23487114 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.7/5

based on 34 Google reviews

5
4
3
2
1
Windsor Grove Health and Rehabilitation Nursing Home in Windsor, VA — Street View
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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (20 vs median 11.0)
  • High RN turnover (73%)

Bottom 25% in VA · Critically understaffed (RN) · Significantly below average staffing · Worst in AVARDIS HEALTH chain · No penalties on record

Source: Medicare data

What this means for your family

While the facility is highly praised for its admissions process and clean environment, the recent report of neglect regarding basic patient hygiene is a serious red flag. We strongly recommend that families conduct an unannounced visit and observe the level of assistance provided to residents during non-peak hours to ensure the care matches the administrative promises.

Google Reviews

Google Reviews

34 reviews on Google
Windsor Grove Health and Rehabilitation receives a high volume of positive reviews, particularly praising the admissions process and the friendliness of the staff. However, a recent critical review highlights serious concerns regarding patient hygiene, lack of assistance with basic needs, and inadequate therapy engagement. Families should be aware of this discrepancy between the facility's administrative reputation and potential lapses in direct bedside care.

Quality Themes

Tap a score for details
FoodN/AStaff8.0Clean9.0Activities7.0MedsN/AMemoryN/AComms9.0ValueN/A

Strengths

  • Efficient and helpful admissions process
  • Clean and well-maintained facility
  • Friendly and welcoming front-desk staff
  • Responsive administrative leadership

Concerns

  • Neglect of basic patient needs and hygiene

Rating Trends

Tap a year to see what changed

2345.02025(34)1.02026(2)

Distribution · 36 analyzed

5
33
4
1
3
0
2
0
1
2
17 reviews posted between Oct 7, 2025Oct 9, 2025 · 17 were 5-star
15 reviews posted between Oct 30, 2025Oct 31, 2025 · 14 were 5-star

How They Respond to Reviews

33%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1Given the facility's current staffing levels, what specific protocols are in place to ensure consistent assistance with daily hygiene and personal care needs?
  • 2I noticed the facility has had a high volume of recent state violations; what specific steps is leadership taking to address these findings and improve the overall quality of care?
  • 3How do you ensure that residents receive timely attention for their basic needs throughout the day and night, especially given the current staffing rating?
  • 4I appreciate how responsive the leadership team is to feedback online; how do you translate that same level of responsiveness into daily communication with families regarding their loved one's health?
  • 5What does a typical daily activity schedule look like for residents to ensure they remain engaged and socially active?
  • 6In the event of a sudden change in a resident's health status, what is your specific process for notifying family members and coordinating with their primary physicians?

Personalized based on this facility's data


Key Review Excerpts

The nursing team is attentive and compassionate, always taking time to answer questions and provide updates. Therapy services are excellent—they work patiently and consistently to help residents regain their strength and independence.

Long-term resident's family · 2025★★★★★

The front receptionist Ashley is always so warm and welcoming, Lindsay in admissions was extremely helpful and knowledgeable, nursing has been very kind and accommodating, there are always activities going on, and the residents there are very taken care of and happy.

Visitor/Family member · 2025★★★★★

This place is ran down and no help! When my mom was there after surgery we were told they don’t do NOTHING but therapy when they are suppose to help. They didn’t give her a pillow, they put her in a diaper and told her to use that because they didn’t want to help her to the toilet.

Rehab patient's family · 2026☆☆☆☆
Source: 34 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.35hrs
47%
Registered nurses for medical care
Total Nursing
2.77hrs
67%
All nurses + aides combined
Staff Turnover
55%
Lower is better (< 30% = good)
RN Turnover
67%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

7

measures

Worse Than Avg

10

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
VA
16.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility76.9%
Worse than Avg
Here
76.9%
US
93.4%
VA
91.0%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility31.1%
Worse than Avg
Here
31.1%
US
19.5%
VA
20.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.3%
Better than Avg
Here
8.3%
US
15.3%
VA
16.4%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility26.2%
Worse than Avg
Here
26.2%
US
19.4%
VA
22.0%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility20.5%
Worse than Avg
Here
20.5%
US
15.5%
VA
14.2%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility49.2%
Worse than Avg
Here
49.2%
US
79.8%
VA
73.6%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility58.0%
Worse than Avg
Here
58.0%
US
81.8%
VA
73.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.0%
Worse than Avg
Here
2.0%
US
1.6%
VA
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

20deficiencies
Above state avg (14.5)
7 complaint-triggered

This facility shows a concerning pattern with 81 deficiencies across recent surveys, including 7 complaint-triggered issues where families filed reports about care problems. The most frequent issues involve medication management, nursing staffing, and infection control, with many problems persisting across multiple years. Most concerning are recent 2024-2025 deficiencies in basic care areas like nutrition, medication errors, and pest control that suggest ongoing quality challenges despite correction claims.

May 1, 2025Routine
22
0725Potential for harm · WidespreadCorrected

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.

0730Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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

0760Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0580Potential for harm · IsolatedCorrected

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.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0656Potential for harm · IsolatedCorrected

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.

0657Potential for harm · IsolatedCorrected

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.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0678Potential for harm · IsolatedCorrected

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.

0685Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0687Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate foot care.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0761Potential for harm · IsolatedCorrected

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.

0925Potential for harm · IsolatedCorrected

Environmental Deficiencies

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

0291Potential for harm · IsolatedCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0293Potential for harm · IsolatedCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0006Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

May 1, 2025Complaint
2
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nov 14, 2024Complaint
5
0919Potential for harm · PatternCorrected

Environmental Deficiencies

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

0925Potential for harm · PatternCorrected

Environmental Deficiencies

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

0584Potential for harm · IsolatedCorrected

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.

0691Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Mar 26, 2021Routine
23
0293Potential for harm · WidespreadCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0761Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0222Potential for harm · PatternCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0345Potential for harm · PatternCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0511Potential for harm · PatternCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0521Potential for harm · PatternCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0567Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0574Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0602Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0622Potential for harm · IsolatedCorrected

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.

0623Potential for harm · IsolatedCorrected

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.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0625Potential for harm · IsolatedCorrected

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.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0689Potential for harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

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

0690Potential for harm · IsolatedCorrected

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.

0758Potential for harm · IsolatedCorrected

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.

0761Potential for harm · IsolatedCorrected

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.

0773Potential for harm · IsolatedCorrected

Administration Deficiencies

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

0775Potential for harm · IsolatedCorrected

Administration Deficiencies

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

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Jun 27, 2019Routine
29
0561Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0610Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0622Potential for harm · PatternCorrected

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.

0625Potential for harm · PatternCorrected

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.

0658Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

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

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

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

0223Potential for harm · PatternCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0521Potential for harm · PatternCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0580Potential for harm · IsolatedCorrected

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.

0582Potential for harm · IsolatedResolved (past non-compliance)

Resident Rights Deficiencies

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

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0584Potential for harm · IsolatedCorrected

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.

0600Potential for harm · IsolatedCorrected

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.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

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.

0657Potential for harm · IsolatedCorrected

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.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0727Potential for harm · IsolatedCorrected

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.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0761Potential for harm · IsolatedCorrected

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0015Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0037Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Windsor Grove Health and Rehabilitation

Organization Type

for profit

Chain Affiliation

Chain Name

Avardis Health

Chain Size

38 facilities nationwide

Chain avg rating: 2.1/5 · Rank 8 of 14 (Worst)

Ownership & Management

Owners

Windsor Parentco LLC

Owner · Organization

100%

Isle of Wight Holdco LLC

Owner (parent company) · Organization

Vaop Holdco LLC

Owner (parent company) · Organization

Key personnel

Hoback, TiffanyManaging Control - Governing BodyMorgan, DanielManaging Control - Governing BodySnf Mgr LLCManagerColburn, JeffreyManagerHoback, TiffanyManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 3 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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