Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsormeade Of Williamsburg during CMS and state inspections, most recent first.
Expired Lorazepam Concentrate was found in a locked box inside the med room refrigerator among medications available for administration. RN #1 said direct care nurses notify the DON when meds need to be removed and the DON destroys discontinued meds. The DON stated the expired medication had been brought to her attention that day.
Dignity Not Maintained During Wound Care: A resident with DM2, generalized muscle weakness, and intact cognition received wound care for a sacral wound. During the observation, an LPN was seen dating and initialing the dressing after it had already been placed on the resident's sacrum; the LPN later stated she would normally date and initial the dressing before applying it due to dignity.
A resident with anemia and intact cognition received Ferrous Sulfate during a med pass, but the RN did not instruct or encourage the resident to drink a full 8 ounces of water with the dose. The RN said she limited water because of the resident’s HF, even though no fluid restriction was ordered; the DON stated that 8 ounces of water is the professional standard for administering Ferrous Sulfate.
Failure to provide ADL care for a resident with lumbar compression fractures and intact cognition was identified when the resident’s fingernails were observed to be excessively long, brownish, and irregularly broken. The resident said he did not have nail clippers and planned to cut them later, while the DON stated the resident would not be returning to a townhouse and staff would provide the needed fingernail care.
Facility staff failed to provide respiratory care consistent with standards of practice for a resident by not changing the oxygen concentrator tubing and humidification bottle as ordered. During an observation, the tubing was past its replace date and the humidifier bottle was dated weeks earlier. The DON stated the tubing should have been changed and said the humidifier bottle did not need to be changed, despite the physician order and facility policy requiring weekly changes of respiratory tubing and the humidifier bottle.
Hospice coordination and symptom management failures were identified for two residents. One resident's record lacked hospice visit notes and a discipline schedule, and a CNA said she was not told when hospice would arrive while an LPN said hospice usually gave an oral report after visits. Another resident with severe cognitive impairment was heard making loud sounds for about 45 minutes without staff response until an LPN was alerted and gave 2 mg of Lorazepam, which calmed the resident.
Nonoperational Resident Bed: A resident’s bed was found not to be functioning properly, with the resident and spouse reporting it could not be raised or lowered for about 2 weeks. CNA staff reported the bed had been repaired, but were unaware of the spouse’s concerns. The DON stated the bed had not been operating properly and that the electrical portion was separating, preventing activation when the controls were pressed.
Expired Lorazepam Found in Medication Refrigerator
Penalty
Summary
Expired medication was found accessible in the medication room refrigerator during an inspection with RN #1. A bottle of Lorazepam Concentrate 2 mg/ml was identified inside a locked box in the refrigerator among other medications available for administration. The bottle had been filled on 01/17/2024 and had an expiration date of 01/2026. RN #1 stated that direct care nurses notify the DON when medications need to be removed, and that the DON was responsible for destroying discontinued medication. During the final interview, the DON stated that the expired medication in the refrigerator had been brought to her attention that day.
Dignity Not Maintained During Wound Care
Penalty
Summary
The facility failed to maintain dignity during wound care for one resident. Resident #20 was admitted with diagnoses including Type 2 diabetes mellitus without complications and generalized muscle weakness, and the admission MDS coded the resident as having intact cognitive abilities for daily decision making with a BIMS score of 13 out of 15. The April 2026 physician orders directed staff to cleanse the sacrum with normal saline, pat dry, apply Medi honey and calcium alginate to the wound bed, and cover with a foam dressing daily and as needed if soiled. During wound care observation, no issues were noted with the wound care itself until the dressing was completed. At that time, LPN #1 was observed dating and initialing the resident's dressing after it had been placed on the resident's sacrum. When interviewed later, LPN #1 stated she would initial and date the resident's dressing before placing it on the sacrum due to dignity. The information was then reviewed with the Administrator, DON, Regional Director of Operations, Regional Nursing Consultant, and Administrator-in-Training, and no additional information was presented.
Failure to Follow Standard Water Amount During Ferrous Sulfate Administration
Penalty
Summary
The facility failed to adhere to professional standards during medication administration for one resident with anemia. The resident had an order for Ferrous Sulfate Oral Tablet 27 mg, 1 tablet by mouth once daily, and the admission MDS coded the resident as cognitively intact with a BIMS score of 14 out of 15. During a medication administration observation, RN #1 assisted the resident in taking 8 pills, including Ferrous Sulfate, and the resident took small sips with the pills until they were swallowed. The resident was not instructed to or encouraged to drink a full glass of water with the medication. When interviewed, RN #1 stated that because the resident had a diagnosis of heart failure, 8 ounces of water was not encouraged, even though no fluid restriction had been ordered by the physician. During the final interview, the DON stated that 8 ounces of water is the professional standard when administering Ferrous Sulfate to aid in dissolving the medication and help prevent constipation.
Failure to Provide ADL Fingernail Care
Penalty
Summary
Facility staff failed to ensure ADL care was provided for 1 of 21 residents, Resident 2. The resident was admitted with lumbar compression fractures, had a BIMS score of 13 out of 15 on the admission MDS, and was coded as needing varying levels of assistance with eating, oral hygiene, personal hygiene, showering/bathing, upper body dressing, lower body dressing, footwear, and toileting hygiene. During observations on 4/16/26 and 4/17/26, Resident 2 was seen in his room on contact precautions with the door closed most of the time. His fingernails were observed to be approximately 2 inches above the fingertips, brownish, and some had broken, irregular edges. The resident stated he did not have his nail clippers with him and would cut them when he returned to his townhouse, and he said he did not like having long fingernails because they get caught on things. During the final interview, the DON stated the resident would not be returning to a townhouse and that staff would provide the necessary fingernail care.
Failure to Change Oxygen Tubing and Humidifier Bottle as Ordered
Penalty
Summary
Facility staff failed to provide respiratory care consistent with professional standards of practice for Resident #18 by not ensuring the oxygen concentrator tubing and humidification bottle were changed according to the physician order. Resident #18 was admitted on 4/6/26 with diagnoses including chronic kidney disease, anxiety disorder, type 2 diabetes mellitus without complications, and essential hypertension. The admission MDS dated 4/13/26 coded the resident as completing the BIMS with a score of 13 out of 15, indicating intact cognitive abilities for daily decision making. During an observation tour on 4/17/26 at 12:05 PM, the oxygen concentrator tubing in the resident's room was observed to read "dispose and replace on 4/16/26," and the humidification bottle attached to the oxygen concentrator was dated 3/25/26. The DON stated the tubing should have been changed on 4/16/26, but also stated the humidifier bottle did not need to be changed and that staff just write the date on the bottle. The physician order dated 04/07/2026 directed staff to change all respiratory tubing weekly, and the facility's Respiratory Assessment Policy stated the oxygen cannula, tubing, and humidifier bottle are changed every week or as needed and should be dated and labeled on the day of change.
Hospice Coordination and Symptom Management Failures
Penalty
Summary
The facility failed to ensure that hospice services were coordinated with the facility plan of care and failed to provide symptom management for two residents. One resident had diagnoses including Alzheimer's disease, TIAs, and urinary retention, and the admission significant change annual quarterly MDS assessment coded a BIMS score of 12 out of 15, indicating moderately impaired cognitive abilities for daily decision-making. The clinical record did not contain hospice visit notes or a schedule of disciplines, and the care plan meeting documentation did not show participation by a hospice agency member. A CNA stated she was never informed when or what time to expect the hospice CNA and cared for the resident as if there was no hospice support, while an LPN stated she did not have a schedule for hospice visits but said the hospice representative usually stopped by after visits and gave an oral report to the nurse. Hospice documentation faxed to the facility was not provided to the survey team until later that day. The facility also failed to assess and manage symptoms for another resident who was admitted with severe cognitive impairment and dependence for all ADLs. During observation, the resident could be heard from the hallway making loud sounds for approximately 45 minutes, and no staff came to the resident's aid during that time. The spouse had to leave the room to speak with a caller because of the resident's loud sounds. An LPN, after being alerted to the resident's status, instructed the spouse not to hesitate to notify staff of any change and administered 2 mg of Lorazepam, which calmed the resident within 10 minutes. The spouse and companion left after the resident quieted and appeared relaxed.
Nonoperational Resident Bed
Penalty
Summary
Keep all essential equipment working safely was cited after surveyors found that the bed for Resident #15 was not operational. The resident was admitted to the facility and had diagnoses listed in the record. The quarterly MDS dated 01/19/2026 coded the resident with a BIMS score of 15 out of 15, indicating intact cognitive abilities for daily decision-making. In section GG0130, the resident was coded as needing partial/moderate assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear; supervision or touch assistance with upper body dressing; and independence with eating, oral hygiene, and personal hygiene. During an interview on 4/17/26 at approximately 12:20 AM, the resident and spouse stated that the bed had not been functioning properly for 2 weeks and that the bed still could not be raised or lowered. Later that day, CNA #1 stated the resident had experienced problems with the bed, but it had been repaired 3 days earlier, and CNA #1 was unaware of the spouse’s concerns. In a final interview with the Administrator, DON, Regional Director of Operations, Regional Nursing Consultant, and Administrator-in-Training, the DON stated the resident bed had not been operating properly but had been repaired, and also stated the concern was secondary to user error because the electrical portion was separating and preventing activation when the controls were pressed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Williamsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Williamsburg Post Acute & Rehabilitation | 3.9 mi | ★★★★★ | 4 | 0 |
| Riverside Lifelong Health & Rehabilitation Patri | 5.5 mi | ★★★★★ | 0 | 0 |
| Woodhaven Hall At Williamsburg Landing | 5.8 mi | ★★★★★ | 6 | 1 |
| Jamestown Health And Rehabilitation | 6 mi | ★★★★★ | 0 | 0 |
| Walter Reed Post Acute | 13.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.