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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Windsor House is a 60-bed assisted living and memory care community at 336 Rhodes Avenue, Windsor, Bertie County, North Carolina,, rated 0 out of 5 overall by the North Carolina Department of Health and Human Services, Division of Health Service Regulation, and ranked 135th (tied) among 138 homes statewide. The facility frames itself as an affordable option for seniors who cannot access traditional assisted living costs, with 24-hour staffing, a Special Care Unit, medication management, insulin administration, and homemade meals confirmed. Neither Medicaid nor Medicare is accepted. Occupancy stands at 47 of 60 beds (78 percent), in line with the North Carolina average of 76.4 percent.
Windsor sits in rural Bertie County in northeastern North Carolina; Vidant Bertie Hospital is the primary nearby acute-care resource.
A 0-star rating and a ranking of 135th out of 138 homes are the first signals families should weigh. Fourteen inspections from December 2015 through August 2025 average 9 deficiencies per year, 73 percent above the North Carolina benchmark of 5.2. Medication management failures and recurring fire safety deficiencies run the length of the record without any clear corrective arc. The most recent inspection, an annual survey and complaint investigation concluded August 7, 2025, found 6 deficiencies: hazardous items accessible to all 47 Special Care Unit residents including pain-relieving patches and batteries; inadequate supervision of 2 residents with documented smoking behaviors; failure to notify providers of swallowing difficulties and abnormal blood sugar for 3 residents; insulin and overactive bladder medication administration errors; and a resident self-administering pain medication without a physician order.
The February 2024 annual inspection was triggered after a resident with dementia eloped and was found sitting in a staff car; 6 deficiencies followed, including the elopement supervision failure, a 12 percent medication error rate, inaccurate controlled substance records, and failure to initiate Health Care Personnel Registry reports for a resident with a bruise of unknown origin. A March 2024 biennial construction follow-up found the fire sprinkler system non-operational since December 11, 2023.
The October 2023 biennial survey cited 9 deficiencies including malfunctioning wanderer alarms, absence of a required resident washer and dryer, exposed electrical hazards, and non-functioning exhaust fans, the last two recurring through the May 2025 follow-up. A January 2023 follow-up documented a resident receiving insulin with blood sugar readings of 597 and too-high-to-register. The September 2022 annual inspection found a 24 percent medication error rate including discontinued medications still administered and falsified records.
Earlier inspections from 2015 through 2018 documented magnetic exit locks not releasing on alarm and recurring fire door and sprinkler failures.
No fines or license suspensions appear in the available record.
Families should ask administrators directly about corrective actions following the 2024 elopement, current sprinkler system status, and the facility’s medication audit and error-reduction protocols.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 22nd out of 90 homes in North Carolina. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 27m per day | ▼ 29% State avg: 38m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 35m per day | ▼ 26% State avg: 47m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 1h 41m per day | ▼ 33% State avg: 2h 30m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 4h 9m per day | ▲ 26% State avg: 3h 17m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 2m per day | ■ Avg State avg: 2m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 16m per day | ▼ 27% State avg: 22m per day · National avg: 28m per day |
Similar to the North Carolina average: 76.4%In North Carolina, the Department of Health and Human Services, Division of Health Service Regulation conducts unannounced surveys to ensure nursing and adult care homes meet safety standards.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the North Carolina state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
| This Facility | NC Average | vs. NC Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 72 | 46 | This facility has 57% more total deficiencies than a typical North Carolina nursing home (72 vs. NC avg 46).↑ 57% worse |
|
Deficiencies per year
Average deficiencies per year since 2015.
| 6.5 | 4.2 | This facility has 55% more deficiencies per year than a typical North Carolina nursing home (6.5 vs. NC avg 4.2).↑ 55% worse |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 2.1 | 2.2 | This facility has 5% fewer deficiencies per inspection than a typical North Carolina nursing home (2.1 vs. NC avg 2.2).↓ 5% better |
Inspections
| This Facility | NC Average | vs. NC Avg |
|---|---|---|---|
|
Total inspections
Combined count of all routine and focused inspections. Excludes complaint investigations.
| 34 | 21 | This facility has 62% more total inspections than a typical North Carolina nursing home (34 vs. NC avg 21).↑ 62% worse |
|
Inspections with deficiencies
Inspections that resulted in at least one regulatory deficiency.
| 31 | 19 | This facility has 63% more inspections with deficiencies than a typical North Carolina nursing home (31 vs. NC avg 19).↑ 63% worse |
|
Inspection deficiency rate
Percentage of inspections that resulted in at least one deficiency.
| 91% | 90% | This facility has 1 percentage point higher inspection deficiency rate than a typical North Carolina nursing home (91% vs. NC avg 90%).↑ 1% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspection on August 7, 2025, identified deficiencies related to hazardous items accessible to residents, inadequate supervision for residents with smoking behaviors, and medication administration issues on the Special Care Unit. Earlier inspections showed a pattern of medication administration and documentation problems, as well as ongoing building maintenance and fire safety system deficiencies. Complaint investigations were substantiated in some cases, including concerns about resident supervision and medication management, but fines or enforcement actions were not listed in the available reports. Prior reports noted issues with fire safety equipment, ventilation, and physical plant maintenance, which have persisted over multiple years. The inspection history indicates continued challenges with health care and safety compliance, with no clear trend of sustained improvement.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsNorth Carolina average 4
Last Health inspection on Nov 2024
North Carolina average 20.9
North Carolina average 4.99
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
All 14 citations resulted from standard inspections.
100% better than North Carolina averageNorth Carolina average: 1.3
100% better than North Carolina averageNorth Carolina average: 0.9
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
33% better than North Carolina average
14% worse than North Carolina average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hoursNo contractors work on this role.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.1 hoursNo contractors work on this role.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
6.7 hoursNo contractors work on this role.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
0 contractor hours this quarter
No contractor roles were reported this quarter.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 22 | 0 | 22 | 4,877 | 92 | 100% | 6.7 |
| Licensed Practical Nurse | 14 | 0 | 14 | 2,693 | 92 | 100% | 7.1 |
| Registered Nurse | 9 | 0 | 9 | 1,726 | 92 | 100% | 7.6 |
| Nurse Practitioner | 1 | 0 | 1 | 541 | 63 | 68% | 8.6 |
| Administrator | 1 | 0 | 1 | 459 | 66 | 72% | 6.9 |
| Other Dietary Services Staff | 1 | 0 | 1 | 453 | 60 | 65% | 7.5 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
8.3
27% better than North Carolina averageNorth Carolina average: 11.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
16.6
20% better than North Carolina averageNorth Carolina average: 20.6
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
16.0%
9% better than North Carolina averageNorth Carolina average: 17.5%
Percent of long-stay residents whose ability to move independently worsened
19.9%
15% better than North Carolina averageNorth Carolina average: 23.3%
Percent of low risk long-stay residents who lose control of their bowels or bladder
13.8%
35% better than North Carolina averageNorth Carolina average: 21.4%
Percent of long-stay residents experiencing one or more falls with major injury
1.2%
68% better than North Carolina averageNorth Carolina average: 3.6%
Percent of long-stay high risk residents with pressure ulcers
4.6%
27% better than North Carolina averageNorth Carolina average: 6.3%
Percent of long-stay residents with a urinary tract infection
7.4%
182% worse than North Carolina averageNorth Carolina average: 2.6%
Percent of long-stay residents who lose too much weight
0.0%
100% better than North Carolina averageNorth Carolina average: 7.4%
Percent of long-stay residents who have depressive symptoms
0.0%
100% better than North Carolina averageNorth Carolina average: 4.4%
Percent of long-stay residents who received an antipsychotic medication
21.2%
58% worse than North Carolina averageNorth Carolina average: 13.4%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
96.5%
5% better than North Carolina averageNorth Carolina average: 91.6%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
100.0%
6% better than North Carolina averageNorth Carolina average: 94.1%
Number of hospitalizations per 1,000 long-stay resident days.
1.71
15% better than North Carolina averageNorth Carolina average: 2.00
Number of outpatient emergency department visits per 1,000 long-stay resident days.
2.47
38% worse than North Carolina averageNorth Carolina average: 1.79
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
92.8%
16% better than North Carolina averageNorth Carolina average: 79.9%
Percent of short-stay residents who newly received an antipsychotic medication
3.3%
124% worse than North Carolina averageNorth Carolina average: 1.5%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
84.6%
8% better than North Carolina averageNorth Carolina average: 78.1%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
27.1%
11% worse than North Carolina averageNorth Carolina average: 24.5%
Percentage of short-stay residents who had an outpatient emergency department visit.
13.9%
21% worse than North Carolina averageNorth Carolina average: 11.5%
Percentage of SNF residents who experience falls with major injury during their stay.
0.0%
100% better than North Carolina averageNorth Carolina average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
19.2%
64% worse than North Carolina averageNorth Carolina average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
47.4%
6% worse than North Carolina averageNorth Carolina average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
67% of new residents, usually for short-term rehab.
33% of new residents, often for short stays.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
20Residents meet regularly to discuss policies, care quality, and activities
Part of a Continuing Care Retirement Community offering multiple care levels
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for Windsor House based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #93 / 97Payroll — State benchmarkedThis home is ranked 93rd out of 97 homes in North Carolina. Shows total annual staff payroll benchmarked to the North Carolina average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Most residents typically stay for a few weeks or months before returning home or moving on.
0.0 miles from city center
Estimated distance in miles from Windsor's city center to Windsor House's address, calculated via Google Maps.
Add your location
Windsor House is located in Windsor, North Carolina.
Here are the financial assistance programs available to residents in North Carolina.
The information below is reported by the North Carolina Department of Health and Human Services, Division of Health Service Regulation.
| Carol Woods |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Chapel Hill (Carol Woods) | 119 | 76.7% | 0% | 5.94 | +239% | +49% | $0 | 7 | 3.5 | - | 23 | A+ | 13 | The Chapel Hill Residential Retirement Center, Inc. | $46.7M | $18.0M | 38.5% | 345199 | ||||
| Brookdale Carriage Club Providence |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Charlotte (Olde Providence North) | 77 | 71.5% | -6% | 8.12 | +78% | +104% | $0 | 11 | 3.7 | - | 8 | A+ | 12 | Bkd Fm Holding Company LLC | $7.1M | $8.1M | 114.8% | 345482 | ||||
| Windsor House |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Windsor | 60 | 78.3% | +2% | 4.71 | +105% | +19% | $0 | 14 | 4.7 | - | 47 | - | 37 | Toni Evans | $6.0M | $2.5M | 41.5% | 345500 | ||||
| Pineville Rehabilitation & Living Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
HC Home Care Professional care delivered in the person's own home — from companionship and errands to skilled nursing and therapy. Allows seniors to age in place. Medicare covers skilled home health when medically necessary.
RC Respite Care Short-term temporary care — days to weeks — to give family caregivers a break. Full care provided during the stay. Often used after hospitalization or to trial a facility before a permanent placement decision. | Pineville (Lakeview Drive) | 106 | 68.3% | -11% | 3.96 | +39% | 0% | $116.0k | 45 | 9.0 | 3 | 84 | A+ | 25 | Ncnh Holdings LLC | $12.1M | $5.7M | 47% | 345415 | ||||
| Walnut Ridge |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Walnut Cove (Windmill Street) | 63 | 100.0% | +31% | 3.12 | -50% | -22% | $40.1k | 23 | 4.6 | 3 | 63 | A+ | 50 | Nita Davis | $12.9M | $3.9M | 29.9% | 345089 |
Windsor House has a walk score of 37. Somewhat walkable. A few nearby services may be reachable on foot, but most trips require transportation.
According to NC state health department records, Windsor House's license number is HAL-008-034.
Windsor House's occupancy is 78%.
Windsor House has 60 beds.
Yes — there are 2 photos of Windsor House in the photo gallery on this page.
Windsor House is located at 336 Rhodes Avenue Windsor, NC 27983.
(888) 969-3694 will put you in contact with the team at Windsor House.
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