Cycle 1
Health 2026-01-13 · Fire 2024-10-15
22 health deficiencies
Top issue: Resident Rights (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Windsor, NC
Windsor Rehabilitation and Healthcare Center
1-star overall rating with 1-star inspections with abuse icon flag with $249,991 in total fines with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1306 South King Street, Windsor, NC
(252) 794-5146
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
1990-12-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing
LPN hours / resident day
0.81
Licensed practical nurse staffing
Aide hours / resident day
1.88
Nurse aide staffing
Weekend hours
2.65
Weekend nurse staffing
RN turnover
75%
Annual RN turnover
Total nurse turnover
82%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
1.8
2.2 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 |
| 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 | 98.5% |
94.1%
4.4 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.6%
1.7 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.8%
3.9 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 17.7% |
7.2%
10.5 pts worse
|
5.4%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.7% |
21.6%
3.1 pts worse
|
19.6%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 25.4% |
15.0%
10.4 pts worse
|
16.7%
8.7 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 | 34.1% |
21.5%
12.6 pts worse
|
16.3%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
16.8%
10.1 pts worse
|
14.9%
12 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 | 3.8% |
2.6%
1.2 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
21.2%
10.7 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
6.0%
3.3 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.3% |
79.9%
10.6 pts worse
|
81.7%
12.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
13.2%
8 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
78.1%
3.8 pts better
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.3% |
22.9%
7.6 pts better
|
23.9%
8.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-15 · Fire 2023-08-10
16 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-08-10 · Fire 2022-05-19
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-02-03
D · Potential for more than minimal harm
2024-10-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-26
D · Potential for more than minimal harm
2024-10-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-26
D · Potential for more than minimal harm
2023-08-10
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-06
F · Potential for more than minimal harm
2022-05-19
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-05-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-05-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-31
F · Potential for more than minimal harm
2022-05-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-05-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-05-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-05-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-04
E · Potential for more than minimal harm
2026-01-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-04
E · Potential for more than minimal harm
2026-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-02-04
C · Minimal harm
2026-01-13
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2026-02-02
D · Potential for more than minimal harm
2025-11-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-11-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-20
F · Potential for more than minimal harm
2025-05-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-28
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-28
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-28
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-06-13
G · Actual harm
2025-05-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-28
G · Actual harm
2025-05-06
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-24
J · Immediate jeopardy
2024-11-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-14
J · Immediate jeopardy
2024-11-26
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-11-14
J · Immediate jeopardy
2024-10-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-14
F · Potential for more than minimal harm
2024-10-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
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 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-14
B · Minimal harm
2024-08-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-16
E · Potential for more than minimal harm
2023-08-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-08-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-30
C · Minimal harm
2023-08-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-08-30
D · Potential for more than minimal harm
2023-03-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-21
Penalties and ownership
What sits behind the stars
$70,220
2025-05-06
Fine
Fine · fine $70,220
Fine
$0
2025-05-06
Payment Denial
Payment Denial · denial start 2025-05-27 · 17 days
17 day denial
$179,771
2024-10-15
Fine
Fine · fine $179,771
Fine
Ownership
Nc East Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Hc Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Zanziper Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Murray, Chris
W-2 Managing Employee · Individual
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#3
Chowan River Nursing and Rehabilitation Center
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