The Vardell Report.Windsor Grove Health and Rehabilitation

Across 4 inspections from June 2019 to May 2025, state surveyors documented 62 findings at Windsor Grove Health and Rehabilitation; 62 have a recorded correction; CMS lists no enforcement action in the window.

Inspections

4

2019–2025, standard and complaint

Findings

62

Deficiencies cited by state inspectors

Corrected

62

Of 62 findings, with a recorded correction date

Penalties

0

No fines or payment denials in the window

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. May 12025

   Standard health inspection

   20 findings

   The same visit included a complaint investigation.

   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Jun 26, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Jun 26, 2025
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Jun 26, 2025
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 26, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level DNo actual harm, potential for moreCorrected Jun 26, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Nov 142024

   Complaint investigation

   5 findings

   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Jan 4, 2025
   • F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level ENo actual harm, potential for moreCorrected Jan 4, 2025
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Jan 4, 2025
   • F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jan 4, 2025
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Jan 4, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Mar 262021

   Standard health inspection

   15 findings

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F567Honor the resident's right to manage his or her financial affairs.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F574The resident has the right to receive notices in a format and a language he or she understands.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F625Notify 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.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 26, 2020
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F775Keep complete, dated laboratory records in the resident's record.Level DNo actual harm, potential for moreCorrected May 7, 2021
   • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected May 7, 2021

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jun 272019

   Standard health inspection

   22 findings

   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level ENo actual harm, potential for moreCorrected Aug 6, 2019
   • F610Respond appropriately to all alleged violations.Level ENo actual harm, potential for moreCorrected Aug 6, 2019
   • F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Level ENo actual harm, potential for moreCorrected Aug 6, 2019
   • F625Notify 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.Level ENo actual harm, potential for moreCorrected Aug 6, 2019
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Aug 6, 2019
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Aug 6, 2019
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Feb 26, 2019
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F727Have 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.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Aug 6, 2019
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 6, 2019

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Nutrition and Hydration, Cited in Three Inspections

   Inspectors cited F692 in June 2019, November 2024 and May 2025. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F692 across all 4 inspections, oldest to newest
2. 2

   Medication Labeling and Storage, Cited in Three Inspections

   Inspectors cited F761 in June 2019, March 2021 and May 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F761 across all 4 inspections, oldest to newest
3. 3

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in June 2019 and May 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F580 across all 4 inspections, oldest to newest
4. 4

   A Clean, Homelike Setting, Cited in Two Inspections

   Inspectors cited F584 in June 2019 and November 2024. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F584 across all 4 inspections, oldest to newest
5. 5

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in June 2019 and May 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F609 across all 4 inspections, oldest to newest
6. 6

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in June 2019 and May 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F610 across all 4 inspections, oldest to newest
7. 7

   Citation F622, Cited in Two Inspections

   Inspectors cited F622 in June 2019 and March 2021. The agency describes it this way: 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. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F622 across all 4 inspections, oldest to newest
8. 8

   Citation F625, Cited in Two Inspections

   Inspectors cited F625 in June 2019 and March 2021. The agency describes it this way: 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. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F625 across all 4 inspections, oldest to newest
9. 9

   Accurate Assessments, Cited in Two Inspections

   Inspectors cited F641 in June 2019 and March 2021. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19212425F641 across all 4 inspections, oldest to newest
10. 10

    Care Plans, Cited in Two Inspections

    Inspectors cited F656 in June 2019 and May 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F656 across all 4 inspections, oldest to newest
11. 11

    Care Plan Timing and Review, Cited in Two Inspections

    Inspectors cited F657 in June 2019 and May 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F657 across all 4 inspections, oldest to newest
12. 12

    Professional Standards, Cited in Two Inspections

    Inspectors cited F658 in June 2019 and May 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F658 across all 4 inspections, oldest to newest
13. 13

    Quality of Care, Cited in Two Inspections

    Inspectors cited F684 in June 2019 and May 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F684 across all 4 inspections, oldest to newest
14. 14

    Accident Hazards and Supervision, Cited in Two Inspections

    Inspectors cited F689 in March 2021 and May 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F689 across all 4 inspections, oldest to newest
15. 15

    Significant Medication Errors, Cited in Two Inspections

    Inspectors cited F760 in June 2019 and May 2025. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F760 across all 4 inspections, oldest to newest
16. 16

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in June 2019 and May 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F880 across all 4 inspections, oldest to newest
17. 17

    Citation F925, Cited in Two Inspections

    Inspectors cited F925 in November 2024 and May 2025. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19212425F925 across all 4 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

   Nutrition and Hydration: cited in three inspections, most seriously at level D.

2. 02

   How are medications stored and secured, and who checks the medication carts?

   Medication Labeling and Storage: cited in three inspections, most seriously at level D.

3. 03

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in two inspections, most seriously at level D.

4. 04

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in two inspections, most seriously at level D.

5. 05

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in two inspections, most seriously at level D.

6. 06

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in two inspections, most seriously at level E.

7. 07

   What changed after F622 was cited, and how do you check it now?

   Citation F622: cited in two inspections, most seriously at level E.

8. 08

   What changed after F625 was cited, and how do you check it now?

   Citation F625: cited in two inspections, most seriously at level E.

9. 09

   Who completes resident assessments, and how are they checked for accuracy?

   Accurate Assessments: cited in two inspections, most seriously at level D.

10. 10

    How is a care plan written and reviewed here, and how do families take part in it?

    Care Plans: cited in two inspections, most seriously at level D.

11. 11

    How often are care plans revised, and who takes part in the review?

    Care Plan Timing and Review: cited in two inspections, most seriously at level D.

12. 12

    How do you check that nurses and aides follow professional standards, and what happens when they do not?

    Professional Standards: cited in two inspections, most seriously at level E.

13. 13

    How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

    Quality of Care: cited in two inspections, most seriously at level E.

14. 14

    What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

    Accident Hazards and Supervision: cited in two inspections, most seriously at level D.

15. 15

    What happened after the medication error citation, and how are high-risk drugs double-checked?

    Significant Medication Errors: cited in two inspections, most seriously at level E.

16. 16

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level D.

17. 17

    What changed after F925 was cited, and how do you check it now?

    Citation F925: cited in two inspections, most seriously at level E.

18. 18

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in May 2025.

19. 19

    Has the home been fined or had payments denied before this record begins?

    CMS lists no fines or payment denials in this window. The record starts June 27, 2019; anything earlier is not in it.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Virginia state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Jun 27, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Mar 26, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection Nov 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Virginia state survey agency

  Inspection May 1, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 495347

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.