Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WINDSOR HEALTH AND REHABILITATION CENTER

STARKE, FL · 120 certified beds · Last Life Safety survey April 17, 2025

CMS Certification Number 105696 · first certified July 1990

Ownership

Operated by SIMCHA HYMAN & NAFTALI ZANZIPER · For profit - Limited Liability company

  • Ownership changed November 3, 2020 (change of ownership)from NF WINDSOR LLC
28
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
8
Inspection & testing records
Of the citations on file

Position within FL

28 citations — more than 99% of the 694 certified nursing homes in FL. Compared within FL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 11. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: July 2026 to March 2027. This facility’s last Life Safety survey was April 2025. Facilities in FL are typically surveyed 15–23 months after the last one (median 17), measured over 729 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

16 of the 28 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index

  • F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  • F-0880 Provide and implement an infection prevention and control program.
  • F-0908 Keep all essential equipment working safely.

How that compares

Citations on file over three years

Compared with the median facility in FL, and nationally. Surveyors differ markedly between states, so the FL figure is the meaningful one.

This facility28FL median7National median11
Citations on file over three years, compared
MeasureCitations
This facility28
Median facility in FL7
Median facility nationally11

Survey history

Citations at each Life Safety survey
212022-0812024-0262025-04
Citations at each Life Safety survey
Survey dateCitations
August 11, 202221
February 1, 20241
April 17, 20256

Most-cited tags

Most-cited tags at this facility
K-03533E-00302E-00221K-03451E-00351K-01001E-00041K-02541
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32025-04-17
E-0030List the names and contact information of those in the facility.22025-04-17
E-0022Establish policies and procedures for sheltering.12022-08-11
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12022-08-11
E-0035Provide family notifications of emergency plan.12022-08-11
K-0100Meet other general requirements.12025-04-17
E-0004Develop and maintain an Emergency Preparedness Program (EP).12025-04-17
K-0254Provide hallway or ground-level exits in all residents' rooms.12022-08-11

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 16
  • Smoke Deficiencies 7
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Construction Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies16
Smoke Deficiencies7
Gas, Vacuum, and Electrical Systems Deficiencies2
Construction Deficiencies1
Egress Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 17, 2025 — 6 citations

Citations issued on April 17, 2025
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (May 13, 2025)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (May 13, 2025)
K-0100Meet other general requirements.Deficient, Provider has date of correction (May 13, 2025)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (May 13, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 13, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (May 13, 2025)

February 1, 2024 — 1 citation

Citations issued on February 1, 2024
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 21, 2024)

August 11, 2022 — 21 citations

Citations issued on August 11, 2022
TagWhat the surveyor checksStatus
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (September 20, 2022)
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (September 20, 2022)
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (September 20, 2022)
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (September 20, 2022)
E-0022Establish policies and procedures for sheltering.Deficient, Provider has date of correction (September 20, 2022)
E-0023Establish policies and procedures for medical documentation.Deficient, Provider has date of correction (September 20, 2022)
E-0024Establish policies and procedures for volunteers.Deficient, Provider has date of correction (September 20, 2022)
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (September 20, 2022)
E-0029Develop a communication plan.Deficient, Provider has date of correction (September 20, 2022)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (September 20, 2022)
E-0032Provide primary/alternate means for communication.Deficient, Provider has date of correction (September 20, 2022)
E-0033Establish methods for sharing information.Deficient, Provider has date of correction (September 20, 2022)
E-0034Provide a means of sharing information on occupancy/needs.Deficient, Provider has date of correction (September 20, 2022)
E-0035Provide family notifications of emergency plan.Deficient, Provider has date of correction (September 20, 2022)
K-0254Provide hallway or ground-level exits in all residents' rooms.Deficient, Provider has date of correction (September 20, 2022)
K-0331Construct fire resistant interior walls.Deficient, Provider has date of correction (September 20, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 20, 2022)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (September 20, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (September 20, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (September 20, 2022)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (September 20, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.