Windsor Rehab: Infection Control Failures Affect 41 - NC
Inspectors visited the facility on May 28, 2025, and documented what they observed during wound care. A nurse and a nurse aide provided treatment to a resident with a chronic wound, and neither wore a gown, as required under Enhanced Barrier Precautions. Enhanced Barrier Precautions, known as EBP, are infection control measures designed to protect residents with chronic wounds or indwelling medical devices from the spread of harmful pathogens. At Windsor, 41 residents required those precautions.
None of the staff had been trained to provide them.
The Assistant Director of Nursing told inspectors she was responsible for training staff on infection prevention. She acknowledged she had not yet started a training program.
The Director of Nursing said she was unaware that staff were not trained or competent in the use of Enhanced Barrier Precautions.
The administrator said she was unsure whether staff had received training on EBP at any time.
Three separate conversations. Three separate admissions. The nurse responsible for training hadn't started. The director responsible for oversight didn't know. The administrator responsible for the facility couldn't say whether training had ever occurred.
What that means practically is this: 41 residents at Windsor Rehabilitation and Healthcare Center, each of them carrying a chronic wound or an indwelling medical device that made them more vulnerable to infection, were receiving care from staff who had never been formally taught the precautions meant to protect them. The gowns that should have been worn during wound care weren't worn, not because a nurse made a one-time mistake, but because no one had built the foundation that would make the right practice routine.
Chronic wounds are not minor inconveniences. They are open pathways. Residents who carry them, particularly in a facility where multiple people share staff, shared spaces, and shared equipment, depend on consistent barrier precautions to keep organisms that live on one person's wound from traveling to another person's body. A gown is not a formality. It is the physical barrier between what a caregiver carries on their clothing from one room and what they introduce into the next.
When inspectors observed the wound care, both the nurse and the aide were without gowns. That was two of the two staff observed. The inspection report does not describe it as an anomaly. It describes it as the practice.
The ADON's admission that she hadn't started a training program suggests this wasn't a gap that developed recently. Training programs don't disappear. They either exist or they were never built. At Windsor, the person charged with building one told a federal inspector, on the afternoon of May 28, that she hadn't begun.
The Director of Nursing's response, that she was unaware staff weren't trained, raises its own questions. Oversight of clinical competency is a core function of a director of nursing. The gap between what the ADON described, a training program that hadn't started, and what the DON believed, that staff were trained and competent, is not a small miscommunication. It is a structural failure in how the facility monitored its own infection control practices.
The administrator's uncertainty was perhaps the most direct summary of the situation. She was unsure if training had happened at any time.
Forty-one residents were waiting for an answer to that question too.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Rehabilitation and Healthcare Center from 2025-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 9, 2026 · Our methodology
Windsor Rehabilitation and Healthcare Center in Windsor, NC was cited for violations during a health inspection on May 28, 2025.
Inspectors visited the facility on May 28, 2025, and documented what they observed during wound care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.