Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Point Continuing Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was left exposed during incontinent care when a nursing assistant left the door open, compromising her privacy. The resident's legs and brief were visible from the hallway, and the privacy curtain was not used. The incident was acknowledged by the nursing assistant and the Director of Nursing.
The facility failed to develop comprehensive care plans for three residents involving anticoagulant, antipsychotic, and oxygen therapies. A resident with heart failure and DVT lacked a care plan for anticoagulant use. Another resident with dementia was on antipsychotic medication without a corresponding care plan. A third resident with respiratory failure used oxygen therapy, but her care plan did not address this. The interim MDS nurse and DON acknowledged these oversights.
A resident with dementia and respiratory failure was observed using an oxygen concentrator with a dirty filter, which had a buildup of dust-like particles. Staff interviews revealed a lack of adherence to cleaning protocols, with one nurse unaware of the need to check and clean the filter. The DON confirmed that nurses should monitor and clean the filters when dirty.
The facility failed to ensure two staff members assigned nurse aide tasks met qualifications. Both staff were performing tasks without completing or enrolling in a state-approved training program. Staff #1, from another country, planned to take the CNA test, while Staff #2, also from abroad, was registered for a future CNA program. Misunderstandings about regulatory requirements were noted among facility administrators.
The facility inaccurately coded the MDS for three residents regarding Gradual Dose Reduction (GDR) and Restraints. Two residents on antipsychotic medications had their GDR reviews omitted from the MDS, while another resident was incorrectly documented as using bed rails as a restraint. Staff interviews confirmed these coding errors.
Privacy Breach During Incontinent Care
Penalty
Summary
The facility failed to maintain personal privacy for a resident during incontinent care. Resident #16, who has severe cognitive impairment and is totally dependent on staff for toilet hygiene, was left exposed when the door to her room was left open approximately 12 inches during care. This allowed the resident's legs and brief to be visible from the hallway, compromising her privacy. The incident occurred while Nursing Assistant (NA) #8 was putting a brief on the resident, and the privacy curtain was not pulled. NA #8 admitted to leaving the door open after getting a nurse to change the resident's dressing and acknowledged that she should have closed it for privacy. The Director of Nursing confirmed that the door should have been closed and the curtain pulled to ensure privacy during care. Resident #16's representative described her as a very private person, emphasizing the importance of maintaining her privacy during such care.
Failure to Develop Comprehensive Care Plans for Critical Medications and Therapies
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents in critical care areas. Resident #22, who was admitted with heart failure, atrial fibrillation, and deep vein thrombosis, was receiving anticoagulant medication as per her medication administration record. However, her care plan did not include a focus on anticoagulant use, which was confirmed by both the interim MDS nurse and the Director of Nursing. Resident #14, diagnosed with dementia, was prescribed Quetiapine Fumarate, an antipsychotic medication, for agitation. Despite receiving this medication routinely, her care plan lacked a focus on antipsychotic use. The interim MDS nurse, who worked part-time, acknowledged the oversight, and the Director of Nursing confirmed that the care plan should have included this focus. Resident #5, with diagnoses of dementia and respiratory failure, had physician orders for oxygen supplementation. Observations confirmed the use of oxygen therapy, yet her care plan did not address oxygen use. The interim MDS nurse and the Director of Nursing both recognized the need for a focused care plan on oxygen use, but the provided hospice care plan did not include specific interventions and goals for oxygen usage.
Failure to Maintain Clean Oxygen Filter for Resident
Penalty
Summary
The facility failed to ensure the cleanliness of an oxygen filter for a resident who was using oxygen therapy. The resident, who had been admitted with diagnoses including dementia and respiratory failure, had a physician's order for oxygen supplementation to maintain oxygen saturation levels above 90%. Observations on two consecutive days revealed that the external air filter of the resident's oxygen concentrator had a buildup of dust-like gray and white particles, indicating it had not been cleaned. Interviews with staff revealed a lack of awareness and adherence to the protocol for cleaning the oxygen filters. Nurse #10 acknowledged the filter was extremely dirty and took action to clean it, while Nurse #11 admitted to not considering the need to check and clean the filter when changing the oxygen tubing. The Director of Nursing confirmed that nurses were expected to monitor and clean the oxygen concentrator filters when they became dirty, highlighting a lapse in the facility's maintenance of respiratory care equipment.
Failure to Ensure Nurse Aide Qualifications
Penalty
Summary
The facility failed to ensure that two staff members, who were assigned nurse aide tasks, met the minimum qualifications for working as nurse aides. Staff #1 and Staff #2 were performing nurse aide tasks without having completed a state-approved training and competency evaluation program or being enrolled in such a program. Staff #1 was hired on October 23, 2024, and was scheduled to work 8-hour shifts performing nurse aide tasks from November 25 to November 28, 2024. She had moved to the US from another country where she was a certified nurse aide, but her certification was not recognized in North Carolina. She planned to take the CNA certification test but had not yet completed or enrolled in a state-approved program. Similarly, Staff #2 was hired on September 16, 2024, and was also scheduled to work 8-hour shifts performing nurse aide tasks during the same period. He had moved to the US from another country where he worked as a caregiver in a hospital. Although he was registered to begin a CNA certification program in December 2024, he had not completed or enrolled in a state-approved training and competency evaluation program. Interviews with the Business Administrator and the Director of Nursing revealed a misunderstanding of the regulatory requirements, as they believed that being in competency skills training at the facility was sufficient, and they were unaware that active participation in a state-approved program was required during the 4-month grace period.
Inaccurate MDS Coding for GDR and Restraints
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents in the areas of Gradual Dose Reduction (GDR) and Restraints. Resident #13, diagnosed with dementia and major depressive disorder, was on antipsychotic medications quetiapine and aripiprazole. A psychiatric Nurse Practitioner noted that a GDR was not recommended, but the MDS assessment failed to document this review, leaving the date blank. Similarly, Resident #16, with dementia and bipolar disorder, was on aripiprazole, and a GDR was not recommended. However, the MDS assessment also omitted this information, leaving the date of the GDR review blank. MDS Nurse #1 acknowledged these errors, stating that the information from the psychiatric Nurse Practitioner should have been included in the MDS. Resident #8, admitted with depression and heart failure, was documented in the MDS as using bed rails as a physical restraint, despite being cognitively intact and having no behaviors indicating the need for a restraint. The physician's orders and progress notes did not support the use of bed rails as a restraint, and both MDS Nurse #1 and the Director of Nurses confirmed that the MDS was coded incorrectly. Resident #8 used bed rails for mobility and assistance with bed mobility and transfers, not as a restraint.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 128 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fuquay-varina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fuquay-varina Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 10 | 0 |
| Unc Rex Rehab & Nursing Care Center Of Apex | 8.5 mi | ★★★★★ | 0 | 0 |
| Highfield Nursing And Rehabilitation | 10.1 mi | ★★★★★ | 15 | 0 |
| Swift Creek Health Center | 10.9 mi | ★★★★★ | 0 | 0 |
| Glenaire | 12.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Windsor Point Continuing Care.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.