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Complaint Investigation

Windsor Rehabilitation And Healthcare Center

Inspection Date: May 28, 2025
Total Violations 2
Facility ID 345339
Location Windsor, NC
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Inspection Findings

F-Tag F880

F-F880: Based on observation, record review and staff interview, the facility failed to: a.) follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when Nurse #1 and Nurse Aide (NA) #1 provided wound care without wearing gowns for 2 of 2 staff observed for infection control (Nurse #1 and NA #1) and b.) to implement their policy for EPB for the 41 residents that required the precautions due to chronic wounds or indwelling medical devices.

An interview was conducted with the Assistant Director of Nursing (ADON) on 5/28/25 at 12:11 PM. The ADON revealed she was responsible for training staff on infection prevention but had yet to start a training program.

In an interview with the Director of Nursing (DON) on 5/28/25 at 12:31 PM. She indicated she was unaware staff were not trained or competent in the use of EBP.

An interview was conducted with the Administrator on 5/28/25 at 1:38 PM. She stated she was unsure if staff received training on EBP at any time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 345339

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F-Tag F880:

Based on observation, record review and staff interview, the facility failed to: a.) follow their infection

control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when Nurse #1 and Nurse Aide (NA) #1 provided wound care without wearing gowns for 2 of 2 staff observed for infection control (Nurse #1 and NA #1) and b.) to implement their policy for EPB for the 41 residents that required the precautions due to chronic wounds or indwelling medical devices.

An interview was conducted with the Assistant Director of Nursing (ADON) on 5/28/25 at 12:11 PM. The ADON revealed she was responsible for training staff on infection prevention but had yet to start a training program.

In an interview with the Director of Nursing (DON) on 5/28/25 at 12:31 PM. She indicated she was unaware staff were not trained or competent in the use of EBP.

An interview was conducted with the Administrator on 5/28/25 at 1:38 PM. She stated she was unsure if staff received training on EBP at any time. 08/26/2025

📋 Inspection Summary

Windsor Rehabilitation and Healthcare Center in Windsor, NC inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Windsor, NC, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Windsor Rehabilitation and Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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