Inspection Reports for Windsor House

The complaint investigation was initiated by the Bertie County Department of Social Services on 06/25/25 related to hazards and supervision concerns on the Special Care Unit.

The facility failed to ensure the Special Care Unit was free of hazards including accessible toiletries, medications, batteries, and other items in resident rooms. The facility also failed to provide adequate supervision for residents with smoking behaviors, failed to notify providers of swallowing difficulties and abnormal blood sugar levels, and failed to administer medications according to orders including insulin and overactive bladder medications. Additionally, the facility did not have self-administration orders for residents who had medications in their rooms.

The facility had deficiencies related to the lack of current fire and building safety inspection reports and failure to maintain exhaust ventilation in specified spaces, including non-working exhaust fans on the 200 Hall. The fire sprinkler system inspection and testing had not been completed as required.

The facility had outstanding deficiencies from the prior Biennial Construction Survey and one new deficiency was identified. Deficiencies included lack of current fire and building safety inspection reports, unclean and unrepaired ceilings and floors, non-operational fire safety equipment including the sprinkler system, and inadequate exhaust ventilation in specified areas.

The complaint investigation was initiated by the Bertie County Department of Social Services on 01/08/24 regarding a resident who eloped from the facility without staff knowledge and was found in a staff car.

The facility failed to provide adequate supervision for a resident with dementia who eloped and was found in a staff car, failed to provide feeding assistance to a resident requiring it, failed to administer medications as ordered for multiple residents including missed doses and incorrect medication orders, failed to maintain accurate medication administration records, failed to reconcile controlled substances properly, and failed to report a bruise of unknown origin on a resident to the Health Care Personnel Registry.

Multiple deficiencies were cited including lack of current fire and building safety inspection reports, malfunctioning wanderer alarms on exit doors, absence of required residential washer and dryer, poor housekeeping and maintenance issues such as sagging ceilings and loose toilet seats, unsafe electrical equipment, fire safety system failures including gaps in fire resistant ceilings, improper fire suppression system nozzle placement, plumbing without required air gaps, and inadequate exhaust ventilation in specified areas.

The facility failed to ensure proper clarification and administration of medication orders for 2 of 4 sampled residents (#1 and #4). Resident #1 was administered the wrong dose of insulin for high blood sugar, and Resident #4 was administered incorrect doses of medications for high blood pressure and elevated ammonia levels. These errors posed significant health risks to the residents.

The complaint investigation was initiated by the Bertie County Department of Social Services on July 1, 2022, related to concerns about lab work and medication administration.

The facility failed to ensure ordered lab work and vital signs were completed for sampled residents, and medications were not administered as ordered, including failure to discontinue medications as directed by providers. These failures posed risks to resident health and safety, constituting Type B violations.

The facility failed to ensure proper health care referral and follow-up for elevated blood sugar levels, failed to implement physician orders for monitoring oxygen saturation, blood pressure, heart rate, and weight, and failed to administer medications as ordered including insulin and antipsychotic medications. Additionally, medication administration records were inaccurate with duplicate orders and incomplete documentation.

Deficiencies were cited related to the electromagnetic locking system failing to meet building code requirements and the lack of a current fire sprinkler inspection report, with ongoing repairs and replacement of panels in progress.

The facility was found to have multiple deficiencies including failure of the electromagnetic locking system to meet building code, lack of current fire sprinkler inspection report, unclean and damaged floors and furnishings, incomplete fire safety rehearsal records, and issues with fire safety equipment such as gaps in sprinkler head escutcheon plates and malfunctioning door latches. Some deficiencies were corrected on site during the survey.

The facility failed to maintain the building and furnishings in good repair and clean condition. Specifically, Resident Room 303 was found missing two drawers in the built-in storage units.

The facility failed to assure physician follow-up and proper wound care for one sampled resident (#1), including missed wound care appointments and incomplete wound treatment. Additionally, the facility failed to properly discontinue and document administration of Metformin medication for the same resident, resulting in medication errors. The facility neglected to maintain residents' rights regarding health care.

The follow-up survey revealed that not all deficiencies have been corrected. Deficiencies include damaged corridor doors, missing drawers in a resident room storage unit, and a missing light bulb in a rear exit light fixture.

The facility failed to maintain the building and furnishings in good repair and clean, maintain the building free of hazards, and keep building equipment safe and operating. Specific issues included damaged towel bars, scarred doors, loose backsplash, stained floors, missing drawers, malfunctioning door hardware, non-releasing magnetic locks on exit doors, fire safety door deficiencies, sprinkler system maintenance issues, electrical fixture problems, and plumbing system failures.