Cycle 1
Health 2025-05-01 · Fire 2025-05-01
20 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Windsor, VA
Windsor Grove Health and Rehabilitation
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
23352 Courthouse Highway, Windsor, VA
(757) 242-4770
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
114
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
2000-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.57
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
2.61
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.03
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.21
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,219
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.06% · Performance 22.03% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.07% · Performance 8.01% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.96
Baseline 59.38% · Performance 51.56% · Measure score 2.96 · Achievement 2.96 · Improvement 1.76
Adjusted total nurse staffing
0
Baseline 3.05 hours · Performance 2.87 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.07% |
10.72%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 19.42% · Lower 95% interval 10.37% |
| Discharge to community | 50.63% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 43.55% · Lower 95% interval 42.22% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.04% |
95.27%
0.8 pts better
|
Numerator 97 · Denominator 101 |
| Falls with major injury | 0.99% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 101 |
| Discharge self-care score | 68.85% |
53.69%
15.2 pts better
|
Numerator 42 · Denominator 61 |
| Discharge mobility score | 47.54% |
50.94%
3.4 pts worse
|
Numerator 29 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 6.93% |
2.29%
4.6 pts worse
|
Numerator 7 · Denominator 101 · Adjusted rate 7.1% |
| Healthcare-associated infections requiring hospitalization | 8.01% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 8.91% · Lower 95% interval 5.06% |
| Staff COVID-19 vaccination coverage | 1.37% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 73 |
| Staff flu vaccination coverage | 11.76% |
42%
30.2 pts worse
|
Numerator 10 · Denominator 85 |
| Discharge function score | 68.85% |
56.45%
12.4 pts better
|
Numerator 42 · Denominator 61 |
| Transfer of health information to provider | 94.12% |
95.95%
1.8 pts worse
|
Numerator 32 · Denominator 34 |
| Transfer of health information to patient | 93.02% |
96.28%
3.3 pts worse
|
Numerator 40 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 22.45% |
25.2%
2.8 pts worse
|
Numerator 11 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.4
0.4 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.4% |
91.2%
12.8 pts worse
|
93.4%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.5% · Q2 82.3% · Q3 75.3% · Q4 79.6% · 4Q avg 78.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
94.0%
1.8 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 4.1% · Q4 4.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.7%
15.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.7%
0.2 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 8.1% · Q3 3.6% · Q4 5.7% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.9% |
20.2%
11.7 pts worse
|
19.6%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 31.0% · Q3 34.1% · Q4 26.4% · 4Q avg 31.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
15.0%
3.8 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.5% · Q3 14.9% · Q4 25.7% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.6% |
17.5%
11.9 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.0% · Q3 5.1% · Q4 5.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.7%
2.9 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 16.5% · Q3 14.1% · Q4 12.4% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.0% |
22.2%
6.8 pts worse
|
19.8%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 27.9% · Q3 33.8% · Q4 30.9% · 4Q avg 29.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.2%
0.8 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.3% · Q3 3.4% · Q4 6.6% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.2% |
74.6%
13.4 pts worse
|
81.7%
20.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.4% · Q2 64.7% · Q3 57.4% · Q4 56.3% · 4Q avg 61.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
11.7%
0.6 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 11.8% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 49.2% |
73.6%
24.4 pts worse
|
79.7%
30.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 49.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
22.0%
0.2 pts worse
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 18.8% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-03-26 · Fire 2021-03-26
20 health deficiencies
Top issue: Resident Rights (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-06-27 · Fire 2019-06-27
22 health deficiencies
Top issue: Resident Rights (7 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-05-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-17
D · Potential for more than minimal harm
2025-05-01
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-17
C · Minimal harm
2025-05-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-06-26
F · Potential for more than minimal harm
2021-03-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-06-02
F · Potential for more than minimal harm
2021-03-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-26
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-02
E · Potential for more than minimal harm
2021-03-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-06-02
E · Potential for more than minimal harm
2019-06-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-08-12
E · Potential for more than minimal harm
2019-06-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-08-12
E · Potential for more than minimal harm
2019-06-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-08-12
D · Potential for more than minimal harm
2019-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-12
D · Potential for more than minimal harm
2019-06-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-08-12
C · Minimal harm
2019-06-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-08-06
C · Minimal harm
2019-06-27
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-08-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-06-26
E · Potential for more than minimal harm
2025-05-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-05-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-26
E · Potential for more than minimal harm
2024-11-14
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-04
E · Potential for more than minimal harm
2024-11-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-01-04
D · Potential for more than minimal harm
2024-11-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-04
D · Potential for more than minimal harm
2024-11-14
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-01-04
D · Potential for more than minimal harm
2024-11-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-04
D · Potential for more than minimal harm
2021-03-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-07-26
D · Potential for more than minimal harm
2021-03-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2021-05-07
D · Potential for more than minimal harm
2021-03-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2021-05-07
E · Potential for more than minimal harm
2019-06-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-08-06
E · Potential for more than minimal harm
2019-06-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-08-06
E · Potential for more than minimal harm
2019-06-27
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2019-08-06
E · Potential for more than minimal harm
2019-06-27
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2019-08-06
E · Potential for more than minimal harm
2019-06-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-08-06
E · Potential for more than minimal harm
2019-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-02-26
D · Potential for more than minimal harm
2019-06-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-08-06
D · Potential for more than minimal harm
2019-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-06
Penalties and ownership
What sits behind the stars
Ownership
Windsor Parentco LLC
5% Or Greater Direct Ownership Interest · Organization
Colburn, Jeffrey
Operational/Managerial Control · Individual
Hoback, Tiffany
Operational/Managerial Control · Individual
Isle Of Wight Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Jones, Tequilla
Operational/Managerial Control · Individual
Morgan, Daniel
Operational/Managerial Control · Individual
Nu C Ii Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nu C Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Snf Care Centers LLC
5% Or Greater Indirect Ownership Interest · Organization
Snf Mgr LLC
Operational/Managerial Control · Organization
Uptegrow, Rachelle
Operational/Managerial Control · Individual
Vaop Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitley, Nakia
Operational/Managerial Control · Individual
Zenith Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Zenith Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Lake Prince Woods, Inc
Suffolk, VA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Autumn Care Of Suffolk
Suffolk, VA
2-star overall rating with 3-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Nans Pointe Rehabilitation And Nursing
Suffolk, VA
2-star overall rating with 1-star inspections with $5,293 in total fines with 29 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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