Cycle 1
Health 2025-12-31 · Fire 2024-11-27
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fuquay-Varina, NC
Windsor Point Continuing Care
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
1221 Broad Street, Fuquay-Varina, NC
(919) 552-4580
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
24
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-03-17
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing
LPN hours / resident day
1.32
Licensed practical nurse staffing
Aide hours / resident day
2.32
Nurse aide staffing
Weekend hours
4.04
Weekend nurse staffing
RN turnover
44%
Annual RN turnover
Total nurse turnover
71%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
91.5%
7.3 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.7% |
7.2%
5.5 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.9% |
21.6%
13.3 pts worse
|
19.6%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
15.0%
8.4 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.5% |
21.5%
1 pts worse
|
16.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
16.8%
1.4 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
2.6%
1.3 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
21.2%
0.3 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.0%
1 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
79.9%
10.9 pts better
|
81.7%
9.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.7% |
1.5%
4.2 pts worse
|
1.6%
4.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.6% |
78.1%
6.5 pts better
|
79.7%
4.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-27 · Fire 2023-10-26
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-10-26 · Fire 2022-07-15
5 health deficiencies
Top issue: Administration (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-10
F · Potential for more than minimal harm
2023-10-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-30
F · Potential for more than minimal harm
2023-10-26
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-30
F · Potential for more than minimal harm
2023-10-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-30
F · Potential for more than minimal harm
2023-10-26
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-01-30
F · Potential for more than minimal harm
2023-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-30
D · Potential for more than minimal harm
2022-07-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-11-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-25
D · Potential for more than minimal harm
2024-11-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-25
D · Potential for more than minimal harm
2024-11-27
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2024-12-25
B · Minimal harm
2024-11-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-25
F · Potential for more than minimal harm
2023-10-26
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-11-23
F · Potential for more than minimal harm
2023-10-26
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-11-23
F · Potential for more than minimal harm
2023-10-26
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-10-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-23
C · Minimal harm
2023-10-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-23
Penalties and ownership
What sits behind the stars
Ownership
Jonhson, Florence
5% Or Greater Direct Ownership Interest · Individual
Evans, Robert
5% Or Greater Direct Ownership Interest · Individual
Evans, Riley
5% Or Greater Direct Ownership Interest · Individual
Evans, Toni
5% Or Greater Direct Ownership Interest · Individual
Miller, Rosemary
5% Or Greater Direct Ownership Interest · Individual
Miller, William
5% Or Greater Direct Ownership Interest · Individual
Sherrill, Debbie
5% Or Greater Direct Ownership Interest · Individual
Buie, Kathyrn
Operational/Managerial Control · Individual
Devine, Michael
Operational/Managerial Control · Individual
Evans, Kisa
Corporate Officer · Individual
Evans, Riley
Corporate Director · Individual
Evans, Riley
5% Or Greater Security Interest · Individual
Evans, Riley
5% Or Greater Mortgage Interest · Individual
Evans, Robert
Operational/Managerial Control · Individual
Evans, Robert
Corporate Officer · Individual
Evans, Robert
5% Or Greater Security Interest · Individual
Evans, Robert
5% Or Greater Mortgage Interest · Individual
Evans, Toni
5% Or Greater Security Interest · Individual
Evans, Toni
5% Or Greater Mortgage Interest · Individual
Jones, Sharon
Operational/Managerial Control · Individual
Jones, Sharon
Corporate Director · Individual
Jonhson, Florence
Operational/Managerial Control · Individual
Jonhson, Florence
Corporate Officer · Individual
Jonhson, Florence
5% Or Greater Security Interest · Individual
Jonhson, Florence
5% Or Greater Mortgage Interest · Individual
Lanzetta, Sharon
Operational/Managerial Control · Individual
Mays, Elizabeth
Operational/Managerial Control · Individual
Miller, Rosemary
5% Or Greater Security Interest · Individual
Miller, Rosemary
5% Or Greater Mortgage Interest · Individual
Miller, William
5% Or Greater Security Interest · Individual
Miller, William
5% Or Greater Mortgage Interest · Individual
Pope, Tammy
Operational/Managerial Control · Individual
Seaverson, Lori
Operational/Managerial Control · Individual
Sherrill, Debbie
5% Or Greater Security Interest · Individual
Sherrill, Debbie
5% Or Greater Mortgage Interest · Individual
Stan Johnson And Associate LLC
5% Or Greater Security Interest · Organization
Stan Johnson And Associate LLC
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Universal Health Care/Fuquay-Varina
Fuquay Varina, NC
1-star overall rating with 1-star inspections with $76,047 in total fines with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
UNC Rex Rehab & Nursing Care Center of Apex
Apex, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Highfield Nursing and Rehabilitation
Cary, NC
1-star overall rating with 1-star inspections with $201,978 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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