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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 34 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
No Medicare penalties on record
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 49% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. The latest standard survey recorded 20 findings, above the VA average of 14.5. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
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
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Concerns
Rating Trends
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Distribution · 36 analyzed
This facility responds to some reviews.
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.”
“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.”
“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.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
7
measures
10
measures
Residents vaccinated for pneumonia
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents on antipsychotic medication
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
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.
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.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
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.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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.
Quality of Life and Care Deficiencies
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
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.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
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.
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.
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.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
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.
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.
Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Administration Deficiencies
Keep complete, dated laboratory records in the resident's record.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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.
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.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
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.
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
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.
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
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.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
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.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Windsor Grove Health and Rehabilitation
for profit
Avardis Health
38 facilities nationwide
Chain avg rating: 2.1/5 · Rank 8 of 14 (Lowest rating)
Owners
Windsor Parentco LLC
Owner · Organization
Isle of Wight Holdco LLC
Owner (parent company) · Organization
Vaop Holdco LLC
Owner (parent company) · Organization
Key personnel
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These are the 3 closest facilities in our data within 10 miles. Proximity does not mean they provide the same care type or have stronger quality signals, so compare each profile and verify services directly.