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Windsor Hills Nursing Center Inspection Report, Violations & Safety Grade (Oklahoma City, Oklahoma)

2416 North Ann Arbor, Oklahoma City, Oklahoma 73127

Phone: 4059428566

CMS Overall:2/5

Overview & Bed Count

Certified Beds
112
Avg Residents/Day
48.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Oklahoma
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
Yes

CMS Star Ratings

Overall2/5
Health2/5
Staffing3/5
Quality2/5

Nurse Staffing Check

MetricThis FacilityOklahoma AvgDifference
RN Hours per Resident per Day0.570.34+0.24
Total Nurse Hours per Resident per Day3.413.82-0.41
CMS Staffing Rating3/52.7/5-
Nursing Staff TurnoverN/A55.4%-

Health Citation History

28 health citations on record

DateCategoryDescriptionSeverity
2025-09-11Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.G – Actual Harm
2025-09-11Infection Control DeficienciesDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.F – Moderate Harm Potential
2025-09-11Resident Rights DeficienciesNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.E – Moderate Harm Potential
2025-09-11Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E – Moderate Harm Potential
2025-09-11Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2025-09-11Environmental DeficienciesMake sure that a working call system is available in each resident's bathroom and bathing area.E – Moderate Harm Potential
2025-09-11Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2025-09-11Quality of Life and Care DeficienciesProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.D – Moderate Harm Potential
2025-05-09Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.J – Immediate Jeopardy
2025-05-09Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.E – Moderate Harm Potential
2024-09-27Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.G – Actual Harm
2024-09-27Resident Rights DeficienciesHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.E – Moderate Harm Potential
2024-09-27Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E – Moderate Harm Potential
2024-09-27Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.E – Moderate Harm Potential
2024-09-27Nutrition and Dietary DeficienciesEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.E – Moderate Harm Potential
2024-09-27Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2024-09-27Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2024-09-27Quality of Life and Care DeficienciesProvide enough food/fluids to maintain a resident's health.D – Moderate Harm Potential
2024-09-27Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2024-09-27Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-09-27Quality of Life and Care DeficienciesEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.E – Moderate Harm Potential
2024-07-26Quality of Life and Care DeficienciesProvide medically-related social services to help each resident achieve the highest possible quality of life.D – Moderate Harm Potential
2024-07-26Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2023-08-09Freedom from Abuse, Neglect, and Exploitation DeficienciesDevelop and implement policies and procedures to prevent abuse, neglect, and theft.E – Moderate Harm Potential
2023-08-09Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.E – Moderate Harm Potential
2023-08-09Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2023-08-09Resident Assessment and Care Planning DeficienciesAssess the resident when there is a significant change in conditionD – Moderate Harm Potential
2023-08-09Infection Control DeficienciesDevelop and implement policies and procedures for flu and pneumonia vaccinations.D – Moderate Harm Potential

Fire Safety Citation History

7 fire safety citations on record

DateCategoryDescriptionSeverity
2025-09-11Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.F – Moderate Harm Potential
2025-09-11Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential
2025-09-11Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.C – Minimal Harm Potential
2025-09-11Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.C – Minimal Harm Potential
2023-08-09Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2023-08-09Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2023-08-09Miscellaneous DeficienciesHave restrictions on the use of portable space heaters.E – Moderate Harm Potential

Total Penalties & Fines

$29,472
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
DateTypeFine AmountPayment Denial
2025-09-11Fine$13,323-
2025-05-09Fine$16,149-

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