01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-01 | 20 | 2025-05-01 | 4 |
| Cycle 2 | 2021-03-26 | 20 | 2021-03-26 | 8 |
| Cycle 3 | 2019-06-27 | 22 | 2019-06-27 | 7 |
CMS CCN 4953472026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Windsor Grove Health And Rehabilitation
23352 Courthouse Highway · Windsor, VA 23487 · Isle Of Wight County
Certified beds114CMS provider file
Recent citation rows81current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
81 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 21 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-05-01 · FIREE0006Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0678Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-06-26 · complaint2025-05-01 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0687Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0725Severity F · widespread; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0760Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-26 · complaint2025-05-01 · HEALTHF0925Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2025-06-262025-05-01 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-10-172025-05-01 · FIREK0293Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2025-10-172025-05-01 · FIREK0761Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-10-1703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- WINDSOR PARENTCO LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 05/01/2025
- ISLE OF WIGHT HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 05/01/2025
- VAOP HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 05/01/2025
- HOBACK, TIFFANYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2025
- MORGAN, DANIELIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/01/2025
- SNF MGR LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2025
- COLBURN, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2025
- HOBACK, TIFFANYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2025
- JONES, TEQUILLAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2025
- MORGAN, DANIELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2025
- UPTEGROW, RACHELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/01/2025
- WHITLEY, NAKIAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2025
- SNF MGR LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/21/2025
- COLBURN, JEFFREYIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2025
- HOBACK, TIFFANYIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/01/2025
- JONES, TEQUILLAIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2025
- MORGAN, DANIELIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2025
- UPTEGROW, RACHELLEIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.71per resident day
RN hours0.37per resident day
Weekend nurse hours2.20per resident day
Staff turnover56.3%CMS reported field
06 / LOCAL RECORDS
Open the Virginia ledger →Other published facilities nearby
No second facility in the same city met the directory rule.