Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Windsor Rehabilitation and Healthcare Center
Windsor, NC · 82 certified beds · Last Life Safety survey October 15, 2024
CMS Certification Number 345339 · first certified December 1990
Ownership
Operated by SIMCHA HYMAN & NAFTALI ZANZIPER · For profit - Corporation
- Ownership changed January 1, 2023 (change of ownership)from SSC WINDSOR BRIAN OPERATING COMPANY LLC
Position within NC
14 citations — more than 71% of the 419 certified nursing homes in NC. Compared within NC 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
The latest survey found 2 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (December 2025 to February 2026), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 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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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
1 of the 14 citations on file is 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 14 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 19, 2022 | 7 |
| August 10, 2023 | 4 |
| October 15, 2024 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-10-15 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2023-08-10 |
| K-0161 | Use approved construction type or materials. | 1 | 2022-05-19 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2022-05-19 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2022-05-19 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2024-10-15 |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | 1 | 2023-08-10 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2022-05-19 |
What the citations cover
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Construction Deficiencies 2
- Egress Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Construction Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 13, 2026 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 3, 2026) |
October 15, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 26, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 26, 2024) |
August 10, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 6, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (October 6, 2023) |
May 19, 2022 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (August 31, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 31, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 31, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 31, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 31, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 31, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 31, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.