Windsor Arbor View

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 5 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's comprehensive care plan reflected his weight bearing status since admission on [DATE] and it was not initiated on his care plan until 07/09/26 (discharge date ). This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for for 1 of 3 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #1 received written notice prior to a room change on 03/04/26 and 04/07/26. This failure could place residents at risk for a decreased quality of life being in a new environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for medication errors. The facility failed to ensure MA A did not administer Resident #1's blood pressure altering medication on 05/23/26 when his blood pressure was not within the required parameters per the physician's order. This failure could place residents at an increased risk for complications, exacerbation of symptoms and disease process, and potential hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for medical records. The facility failed to ensure MA A documented Resident #1's blood pressure on the MAR when the resident's blood pressure altering medication was not administered because it was outside the parameters for administration on 05/29/26. This failure could place residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents out of 8 (Resident #77, Resident #50, Resident #26) that were reviewed for safe environment. The facility failed to ensure bathroom sink water temperatures were between 100-110 degrees Fahrenheit in occupied rooms for Resident #77, Resident #50 and Resident #26. These failures could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries. The Findings Included: 1. Record review of Resident #77's face sheet dated 12/17/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 16 residents (Resident #29, Resident #117, and Resident #9) observed for infection control issues in that: 1. LVN H did not put on PPE when she entered Resident #29's room who was on contact precautions. 2. The facility failed to ensure Resident #117's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 12/15/2025. 3. CNA A failed to hand sanitize before entering and after exiting Resident #9's room. Resident #9 was on Enhanced Barrier Precautions. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1of 8 residents (Resident #44) reviewed for dignity. The facility failed to ensure CNA A did not stand while assisting Resident #44 with lunch on 12/15/25. This failure could place the residents at risk of not having the right to a dignified existence maintained.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for two of eight residents (Resident #44 and Resident #9) reviewed for accidents and hazards. 1. RN G failed to reposition Resident #9 using two employees as required by his care plan. 2. The facility left meal tray within reach for Resident #44 who required assistance with feeding allowing resident to reach drinks on tray. These failures place residents who require assistance with feeding and repositioning at risk of accidents and possible injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for 1 of 6 residents reviewed for intravenous fluids. (Resident #96) The facility failed on 12/15/2025 to ensure the dressing on Resident #96's peripheral intravenous line (a short flexible tube inserted into the vein to administer fluids and medications) was dated and initialed. This failure could place residents at risk of not receiving the appropriate IV care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 26 residents (Resident #43 and Resident #54) reviewed for effective pest control. The facility failed to ensure Residents #43 and #54's room was free of pests. These failures could place residents at risk of exposure to bugs and bug bites.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure LVN B documented on Resident #1's electronic medical record that her foley catheter was re-inserted on 11/24/25. This failure could place residents at risk of not receiving appropriate care through inadequate documentation resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident 21) reviewed for accidents and supervision, in that:The facility failed to ensure Resident #2 received adequate supervision to prevent him from exiting the facility undetected on 06/06/25. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/06/25 and ended on 06/07/2025. The facility corrected the non-compliance before the investigation began. Past Non-Compliance form sent to Administrator on 09/11/25 at 11:49 am. This failure could place the residents at risk for injury or death.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations including abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents by 1 of 1 nurse (LVN E) reviewed for accuracy and completeness of clinical records. The facility failed to ensure LVN E correctly completed Resident #1's assessment on 01/26/25 after her knees gave out and resident was assisted to the floor. This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 3 residents (Resident #1) reviewed for nutritional status. The facility failed to initiate timely interventions to prevent weight loss when Resident #1 experienced significant weight loss of -6.95% (13 pounds) between the dates of 01/10/25 and 02/06/25. This failure could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure that food/ drink items in the reach- in freezer, refrigerator, and dry storage area were properly stored, labeled, and dated and were not expired. These failures could place residents at risk for food contamination.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #11) of three residents reviewed for call lights. The facility failed to ensure Resident #11 had the call light within reach while in bed in his room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #101, Resident #108, and Resident #1) of 4 residents observed for Infection Control. 1. CNA A failed to follow proper infection control while providing incontinent care to Resident #101. 2. CNA B failed to follow proper infection control while providing incontinent care to Resident #108. 3. The facility failed to prevent Resident#1's urinary catheter tubing (bag) from touching the floor. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #2 and Resident #3) of 10 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #2 was coded in the MDS for a fall on 10/18/23. 2. The facility failed to ensure Resident #3 was coded in the MDS for a fall on 4/4/24. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 out of 2 residents receiving breathing treatments that included measurable objectives and time frames to meet residents' needs, for 2 of 2 residents reviewed for care plans belonging to Resident #68 and Resident #10. The facility failed to develop a comprehensive care plan for Resident #10 and Resident #68 to include their breathing treatments. These failures could place residents at risk for their medical, physical, and psychosocial needs not being met.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure review and revision of comprehensive care plans for 1 resident (Resident #72) of 13 residents reviewed for comprehensive care plan revisions in that: The facility failed to review and revise Resident #72's comprehensive person-centered care plan to address the initiation of Haldol Decanoate, an antipsychotic medication. This deficient practice could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #72) of 13 residents whose records were reviewed for pharmacy services. The facility failed to ensure Resident #72 was not prescribed Haldol Decanoate (an antipsychotic) without appropriate diagnosis for its use. This deficient practice could place residents without a diagnosis for taking psychotropic medications at risk for receiving unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 kitchen reviewed in that; Water was observed on the floor of the walk in refrigerator. This failure could place staff at risk of injury while preparing meals for residents.