Public Record
Windsor Health and Rehabilitation Center
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 120
- Avg. residents per day
- 104.9
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 45
- Inspections on file
- 8
- Last inspection
- 2025-12-30
*CMS
*CMS
*CMS
Citations
45 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0584Generalpotential for harm
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.
- 0100Generalpotential for harm
Meet other general requirements.
- 0030Generalpotential for harm
List the names and contact information of those in the facility.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0341Generalpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0640Generalpotential for harm
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007Generalpotential for harm
Address patient/client population and determine types of services needed.
- 0009Generalpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0022Generalpotential for harm
Establish policies and procedures for sheltering.
- 0023Generalpotential for harm
Establish policies and procedures for medical documentation.
- 0024Generalpotential for harm
Establish policies and procedures for volunteers.
- 0026Generalpotential for harm
Establish roles under a Waiver declared by secretary.
- 0029Generalpotential for harm
Develop a communication plan.
- 0030Generalpotential for harm
List the names and contact information of those in the facility.
- 0032Generalpotential for harm
Provide primary/alternate means for communication.
- 0033Generalpotential for harm
Establish methods for sharing information.
- 0034Generalpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035Generalpotential for harm
Provide family notifications of emergency plan.
- 0254Generalpotential for harm
Provide hallway or ground-level exits in all residents' rooms.
- 0331Generalpotential for harm
Construct fire resistant interior walls.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection1 deficiency
- Inspection8 deficiencies
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, interviews, and record reviews, the facility failed to…
Read full statement of deficiencies - View inspection reportInspection8 deficiencies
- Inspection1 deficiency
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT…
Read full statement of deficiencies - Inspection9 deficiencies
F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Review of the admission record for Resident #96 documented the most recent admission date was 9/10/23…
Read full statement of deficiencies - View inspection reportInspection9 deficiencies
- Inspection26 deficiencies
F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to conduct and submit a discharge Minimum Data Set (MDS) assessment…
Read full statement of deficiencies - View inspection reportInspection26 deficiencies
FAQ
Questions and answers
- What is Windsor Health and Rehabilitation Center?
- Windsor Health and Rehabilitation Center is a Medicare- and Medicaid-certified nursing home in Starke, FL, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 105696.
- What is the CMS rating for Windsor Health and Rehabilitation Center?
- Windsor Health and Rehabilitation Center has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Windsor Health and Rehabilitation Center have?
- Windsor Health and Rehabilitation Center is certified for 120 beds. It serves an average of 104.9 residents per day.
- How many citations does Windsor Health and Rehabilitation Center have?
- Windsor Health and Rehabilitation Center has 45 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Windsor Health and Rehabilitation Center last inspected?
- Windsor Health and Rehabilitation Center was last inspected on December 30, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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