Windsor Hills Nursing Center

Inspection history (31)

• September 11, 2025 · D

  Citation F0688

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0688 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide 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. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• September 11, 2025 · E

  Citation F0569

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0569 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• September 11, 2025 · F

  Citation F0882

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0882 (CMS scope/severity F: widespread, no actual harm, potential for more than minimal harm) for Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• September 11, 2025 · D

  Citation F0657

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0657 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• September 11, 2025 · G

  Citation F0600

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0600 (CMS scope/severity G: isolated, actual harm) for Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• September 11, 2025 · E

  Citation F0656

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0656 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• September 11, 2025 · E

  Citation F0919

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0919 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Make sure that a working call system is available in each resident's bathroom and bathing area. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• September 11, 2025 · E

  Citation F0880

  Federal surveyors cited this nursing home on 2025-09-11 under CMS tag F0880 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Provide and implement an infection prevention and control program. The deficiency was recorded as corrected on 2025-10-03. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-09-11.GOV

• May 9, 2025 · J

  Citation F0689

  Federal surveyors cited this nursing home on 2025-05-09 under CMS tag F0689 (CMS scope/severity J: isolated, immediate jeopardy) for Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The deficiency was recorded as corrected on 2025-05-06. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-09.GOV

• May 9, 2025 · E

  Citation F0657

  Federal surveyors cited this nursing home on 2025-05-09 under CMS tag F0657 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. The deficiency was recorded as corrected on 2025-05-13. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-09.GOV

• September 27, 2024 · E

  Citation F0676

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0676 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · E

  Citation F0578

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0578 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Honor 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. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · D

  Citation F0761

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0761 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure 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. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · D

  Citation F0880

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0880 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide and implement an infection prevention and control program. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · E

  Citation F0656

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0656 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · D

  Citation F0641

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0641 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure each resident receives an accurate assessment. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · D

  Citation F0692

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0692 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide enough food/fluids to maintain a resident's health. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · E

  Citation F0812

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0812 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · E

  Citation F0758

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0758 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Implement 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 l…. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

• September 27, 2024 · G

  Citation F0690

  Federal surveyors cited this nursing home on 2024-09-27 under CMS tag F0690 (CMS scope/severity G: isolated, actual harm) for Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. The deficiency was recorded as corrected on 2024-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-27.GOV

Penalties

Total fines on file: $55,026

Staffing

Latest: 3.60 nurse staffing hours per resident per day (2026-06-01)

Ownership

For profit - Limited Liability company

1. Parent organization: Lep Holdings LLC

   parent · PAC 2668713942