Windsor Rehabilitation And Healthcare Center
Windsor Rehabilitation and Healthcare Center in Windsor, NC — inspection on May 28, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.