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Public Record

Windsor Rehabilitation and Healthcare Center

Nursing HomeWindsor, NCCMS 345339
67 citations on record

From CMS

Facility profile

CMS overall rating
1 / 5

*CMS Five-Star

Certified beds
82

*CMS

Avg. residents per day
66.5

*CMS

Inspection record

On record from CMS

Citations on record
67

*CMS

Inspections on file
13

*CMS

Last inspection
2026-01-13

*CMS

Citations

67 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.

  • 0552Generalpotential for harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • 0004Generalpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0842Generalpotential for harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 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.

  • 0602Generalpotential for harm

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0576Generalno actual harm

    Ensure residents have reasonable access to and privacy in their use of communication methods.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0641Generalpotential for harm

    Ensure each resident receives an accurate assessment.

  • 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.

  • 0600Generalpotential for harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0550Generalpotential for harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0585Generalpotential for harm

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0882Generalpotential for harm

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  • 0945Generalpotential for harm

    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

  • 0550Generalpotential for harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0607Seriousactual harm

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0600Seriousactual harm

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0607Generalpotential for harm

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0770Seriousimmediate jeopardy

    Provide timely, quality laboratory services/tests to meet the needs of residents.

  • 0760Seriousimmediate jeopardy

    Ensure that residents are free from significant medication errors.

  • 0745Generalpotential for harm

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 0641Generalpotential for harm

    Ensure each resident receives an accurate assessment.

  • 0609Generalpotential for harm

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0582Generalpotential for harm

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0600Seriousimmediate jeopardy

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0550Generalpotential for harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 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.

  • 0727Generalpotential for harm

    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.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 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.

  • 0842Generalno actual harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0111Generalpotential for harm

    Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

  • 0883Generalpotential for harm

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0760Generalpotential for harm

    Ensure that residents are free from significant medication errors.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0686Generalpotential for harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0698Generalpotential for harm

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0727Generalpotential for harm

    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.

  • 0732Generalno actual harm

    Post nurse staffing information every day.

  • 0745Generalpotential for harm

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 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.

  • 0550Generalpotential for harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0561Generalpotential for harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0867Generalpotential for harm

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0923Generalpotential for harm

    Have proper medical gas storage and administration areas.

  • 0550Generalpotential for harm

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0161Generalpotential for harm

    Use approved construction type or materials.

  • 0321Generalpotential for harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0374Generalpotential for harm

    Install smoke barrier doors that can resist smoke for at least 20 minutes.

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.

Showing the 10 most recent inspections. 4 earlier inspections are also on record.

FAQ

Questions and answers

What is Windsor Rehabilitation and Healthcare Center?
Windsor Rehabilitation and Healthcare Center is a Medicare- and Medicaid-certified nursing home in Windsor, NC, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 345339.
What is the CMS rating for Windsor Rehabilitation and Healthcare Center?
Windsor Rehabilitation and Healthcare Center has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Windsor Rehabilitation and Healthcare Center have?
Windsor Rehabilitation and Healthcare Center is certified for 82 beds. It serves an average of 66.5 residents per day.
How many citations does Windsor Rehabilitation and Healthcare Center have?
Windsor Rehabilitation and Healthcare Center has 67 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Windsor Rehabilitation and Healthcare Center last inspected?
Windsor Rehabilitation and Healthcare Center was last inspected on January 13, 2026. 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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