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
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.58
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.26
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.04
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,056
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9882
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.35
Baseline 51.35% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.01
Adjusted total nurse staffing
3.48
Performance 4.07 hours · Measure score 3.48 · Achievement 3.48 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 5.13% · Lower 95% interval 6.74% |
| Discharge to community | 20.38% |
50.57%
30.2 pts worse
|
Worse than the National Rate · Eligible stays 33 · Observed rate 0% · Lower 95% interval 11.85% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.43% |
8.2%
1.2 pts better
|
Numerator 5 · Denominator 53 |
| Staff flu vaccination coverage | 52.11% |
42%
10.1 pts better
|
Numerator 37 · Denominator 71 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
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 · Q1 95.8% · Q4 100.0% · 4Q avg 98.8% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 0.0% · Q4 4.5% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 1.7% |
| 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 · Q4 30.0% · 4Q avg 34.9% |
| 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 · 4Q avg 23.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 22.5% · Used in QM five-star |
| 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 · 4Q avg 15.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 4.2% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| 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 · Q1 18.0% · 4Q avg 20.9% |
| 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 · Q1 9.2% · Q4 4.3% · 4Q avg 5.0% · Used in QM five-star |
| 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 · Q2 88.5% · Q3 92.3% · 4Q avg 90.8% |
| 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 · 4Q avg 5.7% · Used in QM five-star |
| 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 · 4Q avg 84.6% |
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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