Windsor Grove Health and Rehabilitation

Name: Windsor Grove Health and Rehabilitation
Address: 23352 COURTHOUSE HIGHWAY, Windsor, VA, 23487, US
Telephone: 7572424770

23352 Courthouse Highway, Windsor, VA 23487 · Isle Of Wight County · 114 certified beds · avg 107 residents/day · certified since Aug 1, 2000

Part of chain: AVARDIS HEALTH (38 facilities, chain avg rating 2.0★)

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.48

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (62)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 1, 2025	F · Potential for harm, facility-wide	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
May 1, 2025	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
May 1, 2025	E · Potential for harm, repeated	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
May 1, 2025	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
May 1, 2025	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
May 1, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
May 1, 2025	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
May 1, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 1, 2025	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
May 1, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults.
May 1, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 1, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 1, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Nov 14, 2024	E · Potential for harm, repeated	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Nov 14, 2024	E · Potential for harm, repeated	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint
Nov 14, 2024	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Nov 14, 2024	D · Potential for harm, one-off	The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint
Nov 14, 2024	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Mar 26, 2021	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not honor residents' right to manage their own money and financial affairs.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds.
Mar 26, 2021	D · Potential for harm, one-off	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not keep complete, dated laboratory records in residents' files.
Mar 26, 2021	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Jun 27, 2019	E · Potential for harm, repeated	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Jun 27, 2019	E · Potential for harm, repeated	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Jun 27, 2019	E · Potential for harm, repeated	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Jun 27, 2019	E · Potential for harm, repeated	The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Jun 27, 2019	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jun 27, 2019	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jun 27, 2019	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (15 → 20).

Year	Citations	Worst severity that year
2019	22	E
2021	15	D
2024	5	E
2025	20	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Virginia avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.48	3.67	3.95	top 40% in Virginia; bottom 36% in the U.S.
Registered Nurse hours	0.47	0.66	0.69	bottom 41% in Virginia; bottom 34% in the U.S.
Weekend total nurse staffing	2.82	3.21	3.50	bottom 42% in Virginia; bottom 22% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.24	0.46	0.48	bottom 25% in Virginia; bottom 19% in the U.S.
Total nursing staff turnover (%)	56.3	48.1	45.8	bottom 32% in Virginia; bottom 22% in the U.S.
RN turnover (%)	55.6	48.2	42.9	bottom 37% in Virginia; bottom 28% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.71, RN 0.37, weekend 2.20. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Isle of Wight Holdco LLC	Organization	5% or Greater Indirect Ownership Interest	—	05/01/2025
Vaop Holdco LLC	Organization	5% or Greater Indirect Ownership Interest	—	05/01/2025
Windsor Parentco LLC	Organization	5% or Greater Direct Ownership Interest	100%	05/01/2025
Colburn, Jeffrey	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
Colburn, Jeffrey	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2025
Hoback, Tiffany	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2025
Hoback, Tiffany	Individual	Operational/Managerial Control	NOT APPLICABLE	06/01/2025
Hoback, Tiffany	Individual	ADP of the SNF	NOT APPLICABLE	06/01/2025
Jones, Tequilla	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
Jones, Tequilla	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2025
Morgan, Daniel	Individual	Managing Control - Governing Body	NOT APPLICABLE	05/01/2025
Morgan, Daniel	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
Morgan, Daniel	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2025
SNF Mgr LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
SNF Mgr LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/21/2025
Uptegrow, Rachelle	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
Uptegrow, Rachelle	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2025
Whitley, Nakia	Individual	Operational/Managerial Control	NOT APPLICABLE	06/01/2025
Whitley, Nakia	Individual	ADP of the SNF	NOT APPLICABLE	03/06/1972

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
"How often do you evaluate your nurse aides and what ongoing training do they receive?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Lake Prince Woods, INC	7.4 mi	Suffolk, VA	★★★★★	5/5
Autumn Care of Suffolk	9.0 mi	Suffolk, VA	★★☆☆☆	3/5
Nans Pointe Rehabilitation and Nursing	10.7 mi	Suffolk, VA	★☆☆☆☆	1/5
Riverside Lifelong Health & Rehab Smithfield	13.6 mi	Smithfield, VA	★★★★☆	4/5
Southampton Memorial Hosp	13.7 mi	Franklin, VA	★★★★★	4/5
Northern Cardinal Rehabilitation and Nursing	18.1 mi	Suffolk, VA	★☆☆☆☆	2/5
Courtland Rehabilitation and Healthcare Center	18.7 mi	Courtland, VA	★☆☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Windsor →

Facility data as of CMS processing date 2026-08-01. CCN 495347.

The Care File

Visit checklist — Windsor Grove Health and Rehabilitation

23352 Courthouse Highway, Windsor, VA 23487 · 7572424770

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $0

Questions for the administrator:

☐ "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
☐ "How often do you evaluate your nurse aides and what ongoing training do they receive?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 495347 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)