Windsor Hills Nursing Center

In the surveyor’s words

From the most serious findings on record at Windsor Hills Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 9, 2025

  On 05/09/25 at 10:15 a.m., a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure residents were monitored for safe smoking and the use of electronic vaping devices. Resident #1 was a known vape device user, in their room with continuous oxygen use. Resident #1 did not have a care plan that addressed the vape device, and the use of the device in their room. Staff confirmed the knowledge of the use of the vaping devices in the room and they charged them. On 05/02/25, Resident #1 while in their room with oxygen on lit a cigarette causing flash burns to his face. […]

• Actual harm, patternF689Jul 25, 2023

  Based on observation, record review, and interview, the facility failed to ensure residents were provided supervision to prevent falls and implement interventions to prevent falls for two (#1 and #2) of three sampled residents reviewed for falls. Resident #1 had seven falls without having any interventions in place and sustained a fracture to the face on 05/09/23. Resident #2 had 22 falls in a six month period without changes in fall interventions and sustained hematoma, bruising, and lacerations that required stitches. The DON identified 43 residents who were moderate to high risk for falls. […]

• Actual harm, isolatedF600Sep 11, 2025

  Based on observation, record review, and interview, the facility failed to ensure a resident was not touched sexually by another resident for 1 (#3) of 3 sampled residents reviewed for abuse. The facility's failure to prevent this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm.The administrator identified 54 residents resided in the facility. On 09/08/25 at 10:43 a.m., Resident #3 was observed lying in bed, with the bed in the low position, with fall mat in place. Their room was clutter free and the trash can was empty. Resident #3's room was next to the nurse's station on hall 300. […]

• Actual harm, isolatedF690Sep 27, 2024

  Based on record review and interview, the facility failed to ensure a physician's order for monthly catheter changes was followed and failed to ensure a resident with a indwelling urinary catheter received services to help prevent urinary tract infections for one (#35) of two sampled residents reviewed for catheters. The deficient practice resulted in a bladder stone. The MDS Resident Matrix, dated 09/23/24, identified four residents with catheters. Findings: A Clinical Supplies in Case of Emergency policy, reviewed 09/17/24, read in part, It is the policy of this facility to establish procedures to ensure that needed clinical supplies are available to maintain continuity of care in the case of emergency. […]

• Actual harm, isolatedF760Jan 18, 2023

  A past noncompliance with harm was determined to exist effective 01/12/23 related to the facility's failure to provide correctly administered pain medication. The facility failed to follow their medication administration policy which resulted in a resident being sent to the ER for treatment of Narcan. The resident was sent from the facility 01/12/23 at 8:08 a.m., to the ER and was returned to the facility 01/13/23 at 5:11 p.m. On 01/18/23 at 10:45 a.m., the Oklahoma State Department of Health verified the existence of the past noncompliance with harm related to the improper administration of pain medications to a resident. […]