Report
TheVardellReport
Windsor Hills Nursing Center
Skilled nursing facility and nursing facility
2416 North Ann Arbor
Oklahoma City, OK 73127
Report
← Windsor Hills Nursing Center, free profile
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The Vardell Report.Windsor Hills Nursing Center
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Oklahoma City, OK
- Record Period
- 2023–2025
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 5 inspections from August 2023 to September 2025, state surveyors documented 28 findings at Windsor Hills Nursing Center; 28 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 5
- 2023–2025, standard and complaint
- Findings
- 28
- Deficiencies cited by state inspectors
- Corrected
- 28
- Of 28 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 1 | 5 | 0 |
| 2024 | 2 | 13 | 1 |
| 2025 | 2 | 10 | 2 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 28 of 28 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $29,472, their payment not published.
- 4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, September 11, 2025, recorded 8 findings (most serious: Level G).
Report at a Glance
- Facility
- Windsor Hills Nursing Center
- Address
- 2416 North Ann Arbor, Oklahoma City, OK 73127
- CMS Certification Number
- 375400
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 112
- Ownership
- For profit - Limited Liability company
- Record Window
- August 9, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Standard health inspection
8 findings
The same visit included a complaint investigation.
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Oct 3, 2025
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level FNo actual harm, potential for moreCorrected Oct 3, 2025
- F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Level ENo actual harm, potential for moreCorrected Oct 3, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Oct 3, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Oct 3, 2025
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level ENo actual harm, potential for moreCorrected Oct 3, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Oct 3, 2025
- F688Provide 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.Level DNo actual harm, potential for moreCorrected Oct 3, 2025
Enforcement Action
Civil money penalty, $13,323 imposed September 11, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 11, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected May 6, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected May 13, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
11 findings
The same visit included a complaint investigation.
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level GActual harmCorrected Oct 29, 2024
- F578Honor 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.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
- F758Implement 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.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
- F803Ensure 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.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Oct 29, 2024
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level ENo actual harm, potential for moreCorrected Oct 29, 2024
Enforcement Action
Civil money penalty, $16,149 imposed May 9, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 27, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected Aug 1, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Aug 1, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
5 findings
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level ENo actual harm, potential for moreCorrected Aug 25, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Aug 25, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Aug 25, 2023
- F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Aug 25, 2023
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Aug 25, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Care Plans, Cited in Two Inspections
Inspectors cited F656 in September 2024 and September 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242525F656 across all 5 inspections, oldest to newest - 2
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in May 2025 and September 2025. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242525F657 across all 5 inspections, oldest to newest - 3
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in August 2023 and July 2024. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242525F755 across all 5 inspections, oldest to newest - 4
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in August 2023 and September 2024. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242525F812 across all 5 inspections, oldest to newest - 5
Infection Control, Cited in Two Inspections
Inspectors cited F880 in September 2024 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2324242525F880 across all 5 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level E.
- 02
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level E.
- 03
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level E.
- 04
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level E.
- 05
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E.
- 06
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 07
What led to the 2025 fine, and has it been paid?
A $13,323 civil money penalty was imposed September 11, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oklahoma state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oklahoma state survey agency
Inspection Aug 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oklahoma state survey agency
Inspection Jul 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oklahoma state survey agency
Inspection Sep 27, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oklahoma state survey agency
Inspection May 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oklahoma state survey agency
Inspection Sep 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 375400
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowAugust 9, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before August 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.