The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited May 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
Nursing home report
Windsor Grove Health and Rehabilitation
WINDSOR, VA · Medicare-certified · 114 beds
Needs attention
For-profitChain member
1 of 5 overall
Windsor Grove Health and Rehabilitation has a 1-star overall rating, with very low staffing (1 star) and nurse staffing below the federal benchmark (2.77 vs. 4.1 hours per resident per day). It has no fines in the last 24 months, but it is flagged for the lowest overall rating and recent inspection concerns included insufficient nursing staff, inadequate nurse aide oversight/training, and medication errors.
Facility ratings
Health inspections
Staffing
2.7673 hrs/resident/day
Quality measures
Last inspection: May 1, 2025Penalties, last 24 months: $0lowest overall rating
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.7673.
Staffing detail
- Registered nurses
- 0.35
- Licensed practical nurses
- 0.81
- Nurse aides
- 1.61
- Weekend nursing
- 2.34
Hours per resident per day.
Total staff turnover: 55%
Registered nurse turnover: 67%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
20.5%Worsening
Residents with a fall causing major injury
3.8%Worsening
Residents with pressure ulcers (bedsores)
4.5%Worsening
Residents with a urinary tract infection
0%Steady
Residents who lost too much weight
6.5%Steady
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
13.5%Improving
Residents whose ability to walk got worse
8.3%Worsening
Show all measures
Long-stay residents on antianxiety or sleep medication
31.1%Worsening
Short-stay residents newly given an antipsychotic
2%Worsening
Residents with a long-term catheter
0.2%Improving
Residents with new or worsening incontinence
26.2%Improving
Residents with depressive symptoms
0%Steady
Long-stay residents given the seasonal flu vaccine
92.2%Steady
Long-stay residents given the pneumonia vaccine
76.9%Worsening
Short-stay residents given the seasonal flu vaccine
49.2%Steady
Short-stay residents given the pneumonia vaccine
58%Worsening
What the inspectors found
The home failed to properly watch nurse aides' work and provide regular training. Cited May 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 730 — 42 CFR §483.35(e)(7) — S/S: E
The nursing home failed to ensure residents were free from significant medication errors. Cited May 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: E
The nursing home failed to make sure it had a pest control program to prevent or deal with mice, insects, and other pests. Cited November 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 925 — 42 CFR §483.90 — S/S: E
The nursing home failed to ensure a working call system was available in each resident’s bathroom and bathing area. Cited November 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 919 — 42 CFR §483.90 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 20 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 5 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 15 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of AVARDIS HEALTH · 38 homes · 2 stars avg
- Occupancy
- 109.2 residents on an average day (96% of 114 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 25 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.