Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Winds Living Center during CMS and state inspections, most recent first.
A deficiency was identified when a resident engaged in aggressive and threatening behavior toward another resident, including verbal abuse, threats, and physical actions such as throwing objects. The targeted resident experienced significant fear and psychosocial distress as a result. Facility staff intervened to remove the aggressive resident, but the incident revealed a failure to fully protect the resident from psychosocial abuse as required by policy.
A deficiency was identified when a resident exhibited aggressive and threatening behavior toward another resident, resulting in physical and emotional distress. The facility failed to conduct a thorough investigation, as required by policy, by not including additional staff or resident interviews in the incident file, despite multiple witnesses and the affected resident expressing fear and anxiety.
A resident's complete advance directive was not included in their medical record, with only one page present and the remainder missing. Staff interviews indicated that the social service director had assisted the resident, who was cognitively intact, in completing the advance directive, but the missing pages may not have been scanned back into the chart after a hospital transfer. The DON confirmed the resident's wishes for a DNR but could not provide full documentation.
A resident with chronic respiratory conditions was observed using oxygen tubing that had not been changed according to the weekly schedule ordered by the physician. The tubing was labeled with an outdated date, and both the resident and staff confirmed it had not been replaced as required.
A resident was mistakenly administered another resident's evening medications, including duloxetine, melatonin, clozapine, dicyclomine, and metformin. The error was discovered after a medication aide reported missing medications, prompting a review of the medication cart and records. The resident who received the wrong medications was assessed and found to be stable, with no immediate adverse effects observed. Staff interviews indicated that standard verification procedures were in place, but the error was not initially recognized, and incident documentation was incomplete until later amended.
A facility failed to ensure EBP signage was posted for a resident on dialysis with end stage renal disease, despite physician orders and available PPE supplies. Staff interviews revealed confusion about signage responsibilities and inconsistent PPE use, with the DON ultimately confirming the absence of required signage.
Two residents received antibiotics without documented infection assessment screenings or laboratory results, despite facility policy requiring such protocols as part of its antibiotic stewardship program. Staff interviews confirmed that screening tools were not completed at the time of antibiotic administration, and decisions were made based on physician orders without the required documentation.
Failure to Protect Resident from Psychosocial Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from psychosocial abuse. The incident involved a resident who engaged in aggressive and threatening behavior, including yelling explicit and derogatory language, making threats of physical harm, and attempting to enter another resident's room. The aggressive resident was observed slinging a wet floor sign and throwing it at a door, which struck an LPN, and subsequently throwing a chair. The targeted resident remained in their room with the door shut during the altercation and did not provoke the incident. Following the event, the targeted resident expressed significant fear and distress, reporting to staff that the threats and yelling caused chest pain and shaking. The resident voiced concerns about their safety, particularly at night, and indicated that the only time they experienced such symptoms was during the incident. The aggressive resident was sent to the emergency room for evaluation and did not return to the facility. The facility's policy required immediate intervention to halt abusive behaviors and ensure resident safety, including removing the abusive resident and providing supervision. However, the report indicates that the facility did not fully implement all aspects of its policy during the incident. There were no additional resident or staff interviews included in the initial investigation, and the targeted resident's psychosocial distress was not immediately addressed beyond reassurance after the aggressive resident was removed.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of abuse involving two residents. The incident began when one resident engaged in aggressive and threatening behavior, including yelling profanities, making threats, and attempting to enter another resident's room while wielding a wet floor sign and a chair. The aggressive resident threw the wet floor sign, which struck an LPN, and also threw a chair toward a door. Multiple staff members attempted to de-escalate the situation, and the resident was subsequently sent to the emergency room for evaluation and did not return to the facility. Documentation shows that the altercation caused significant distress to the other resident, who reported feeling scared, experiencing chest pain, and anxiety due to the threats made outside their door. The resident expressed concerns about their safety, particularly regarding the possibility of being attacked while asleep. Despite these concerns and the presence of multiple witnesses, the facility's investigation into the incident was incomplete, as there were no additional resident or staff interviews included in the investigation file. The facility's policy required immediate intervention and a thorough investigation of alleged abuse, including interviews and documentation of findings. However, the investigation lacked critical interviews and safe surveys, which were reportedly conducted but could not be located. This failure to fully document and investigate the abuse allegation led to the determination of non-compliance and the identification of an Immediate Jeopardy situation by the state health department.
Incomplete Advance Directive Documentation in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's complete advance directive was included in their medical record. Upon review, only one page of the resident's advance directive, specifically part four general provisions, was found in the clinical record, while the remaining pages were missing. Documentation showed that the resident had executed an advance directive, and a quarterly assessment indicated the resident had intact cognition. The facility's policy requires that information about whether a resident has executed an advance directive be displayed prominently in the medical record. Interviews with facility staff revealed that the social service director was aware the resident had an advance directive, as they had assisted in its completion, but was unsure of the location of the missing pages. The social service director suggested that the missing documentation might not have been scanned back into the resident's chart following a hospital transfer. The DON confirmed that the resident had marked the advance directive, specifically indicating a desire for a DNR, but was unable to provide documentation clarifying this information.
Failure to Change Oxygen Tubing Per Physician Order
Penalty
Summary
The facility failed to ensure that a resident's oxygen tubing was changed according to the physician's order and standard practice. Observations on two separate dates showed the resident wearing oxygen tubing labeled with a date from over a month prior, despite a physician order specifying that the tubing and humidifier bottles should be changed weekly on Sundays during the night shift. The resident, who had diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure, was unable to recall when the tubing was last changed and acknowledged it was likely due for replacement. Both an LPN and the Director of Nursing confirmed that the tubing was not dated appropriately and should have been changed weekly as per the order and facility protocol.
Medication Administration Error: Resident Given Another's Medications
Penalty
Summary
A medication administration error occurred when a resident was given another resident's evening medications. The facility's policy required medications to be administered safely, timely, and as prescribed, with errors documented and reviewed. On the evening in question, a medication aide reported missing medications for one resident, which led to the discovery that those medications had been administered to a different resident in error. The medications given in error included duloxetine, melatonin, clozapine, dicyclomine, and metformin. The resident who received the wrong medications had diagnoses including anxiety disorder, major depressive disorder, diabetes mellitus, and bipolar disorder. Following the error, the resident was assessed and found to be alert and oriented, with stable vital signs and no immediate adverse reactions observed. The error was identified after the medication aide and nursing staff reviewed the medication cart and administration records, realizing that the medications intended for one resident had been given to another. Interviews with staff revealed that medication administration procedures included verifying resident names, photos, and medication orders. However, staff involved in the incident were initially unaware of the error until the discrepancy was investigated. Documentation of the incident was initially incomplete, lacking details about which medications were given in error and to whom, and was later amended to include this information.
Failure to Post Enhanced Barrier Precaution Signage for Dialysis Resident
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precaution (EBP) signage was in place for a resident requiring infection control measures. Observations on multiple occasions revealed that there was no EBP signage inside or outside the resident's room, despite a physician's order for EBP every shift due to end stage renal disease and dialysis. Supplies such as gowns, shields, masks, and gloves were available in a cabinet near the room, but the required signage to indicate EBP precautions was missing. Interviews with staff confirmed that there were two residents on EBP for dialysis, and that signage was supposed to be posted on or near the door, but it was not present for this resident. Staff interviews indicated confusion and inconsistency regarding the responsibility for posting EBP signage, with some staff stating it was the DON's responsibility and others noting that residents sometimes removed the signs. The DON initially stated that signage was present but later confirmed its absence upon inspection. The resident involved was cognitively intact, received dialysis, and had a diagnosis of end stage renal disease. The lack of proper signage led to uncertainty among staff about which residents were on EBP and inconsistent use of personal protective equipment (PPE) when caring for the resident's dialysis catheter.
Failure to Utilize Infection Assessment Screening for Antibiotic Stewardship
Penalty
Summary
The facility failed to utilize an infection assessment screening to determine the necessity of antibiotic use for two of five sampled residents reviewed for antibiotic stewardship. According to the infection prevention and control program policy, an antibiotic stewardship program, including protocols and a system to monitor antibiotic use, was to be implemented. However, record review showed that one resident received zithromax for an upper respiratory infection and another received azithromycin and later doxycycline for a skin infection, with no laboratory results or infection assessment screenings documented in their clinical records for these antibiotic treatments. Interviews with the DON and director of clinical services revealed that the facility claimed to use the McGreer and Loeb screening tools for antibiotic stewardship, with infection screening evaluations supposedly located under assessments in the clinical record. Despite these claims, the last documented infection screening evaluation for one resident was several months prior to the antibiotic administration, and no screening tools were found for the relevant infection episodes. The DON confirmed that antibiotic appropriateness was determined based on physician orders, but there was no evidence of the required infection assessment screenings being completed at the time antibiotics were prescribed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oklahoma City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor | 1.3 mi | ★★★★★ | 15 | 0 |
| The Lodge At Brookline | 1.3 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Okc, Llc | 1.8 mi | ★★★★★ | 9 | 0 |
| Windsor Hills Nursing Center | 1.9 mi | ★★★★★ | 12 | 0 |
| Bellevue Health & Rehabilitation Center | 2 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.