Windsor Rehabilitation And Healthcare Center

F 0550

anymore, as he was soon scheduled to leave the facility for home.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Windsor Rehabilitation and Healthcare Center

1306 South King Street Windsor, NC 27983

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record reviews, staff interviews, and a resident interview, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse when Resident #3 struck Resident #4, resulting in a bruise to

the right side of the face. This occurred for 1 of 3 residents reviewed for abuse (Resident #4). Findings included:Resident #3 was readmitted to the facility on [DATE REDACTED].Documentation on an annual Minimum Data Set assessment dated [DATE REDACTED] revealed Resident #3 was cognitively intact.Resident #4 was admitted to the facility on [DATE REDACTED].Documentation on a quarterly Minimum Data Set assessment dated [DATE REDACTED] revealed Resident #4 had moderately impaired cognition.Documentation in a behavior note for Resident #3 dated 8/27/2025 at 2:45 PM written by the Assistant Director of Nursing (ADON) revealed the following information. The ADON heard yelling in the dining room area and went to the dining room. Resident #3 indicated to the ADON that Resident #4 needed help getting through the doorway in his wheelchair from

the outside. Resident #4 began to curse and call Resident #3 a racially charged name. As the ADON removed Resident #4 from the doorway, both Resident #3 and Resident #4 began to curse at each other.

Resident #3 propelled himself in his wheelchair toward Resident #4 with his hand raised to hit him. The ADON told Resident #3 not to hit Resident #4, but Resident #3 then slapped Resident #4 on the right side of the face. Resident #4 was assisted in his wheelchair to the nursing station.The ADON was interviewed

on 10/8/2025 at 12:11 PM. The ADON confirmed Resident #3 struck Resident #4 as she was attempting to pull Resident #3 out of the way. The ADON indicated Resident #4 refused to stop calling Resident #3 a racially charged name so Resident #3 slapped him. The ADON stated afterward the police were called and Resident #4 could not recall the incident. The ADON confirmed Resident #3 was charged with assault and had already made an initial court appearance. The ADON confirmed Resident #4 had a small bruise on the right side of his head after being struck by Resident #3.Resident #3 was interviewed on 10/8/2025 at 11:40 AM. Resident #3 explained that Resident #4 was outside and was trying to get into the building but was stuck in the doorway. Resident #3 further explained that he shouted for help until the ADON came into the dining room and he pointed to Resident #4 to let her know he was the one who needed help. Resident #3 stated that Resident #4 started cursing at him and called him a racially charged named that was very disrespectful. Resident #3 revealed he tried to hit Resident #4 but never made contact because the ADON pulled Resident #4 out of the way. Resident #3 confirmed the police were called but the ADON told the police Resident #3 struck Resident #4. Resident #3 confirmed he had already been to court, and the case had a continuation date. Resident #3 explained that Resident #4 had apologized to him and there were no further issues or problems between the two residents.Resident #4 was interviewed on 10/8/2025 at 11:50 AM. Resident #4 did not recall any incident or occasion for which he was slapped or hit at the facility.

Resident #4 denied knowledge of any altercations he had involving Resident #3.The Administrator was interviewed on 10/8/2025 at 2:12 PM. The Administrator stated that after Resident #3 hit Resident #4 the police were called. The Administrator confirmed Resident #3 was charged with assault. The Administrator also confirmed Resident #4 was assessed by a provider, ice was applied to his face, and he was moved to

a different hallway away from Resident #3. The Administrator stated Resident #3 and Resident #4 have not had any further issues.

Event ID:

Facility ID:

If continuation sheet