Windsor Atrium

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pharmacist reported any drug regimen irregularities to the attending physician, the facility's medical director and the Director of Nurses, for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to detect and/or report drug regimen irregularities related to drug-to-drug interaction between Ibuprofen and Prozac which had a severe risk of gastrointestinal bleed. This facility failure could place residents at risk for harm related to drug-to-drug interactions that could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 6 residents reviewed for medical records accuracy. The facility failed to provide any MH NP documentation for the start and stop of psychotropic medications in the Progress Notes for Resident #1 on 03/08/2026. This failure could place residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview and record reviews, in accordance with accepted professional standards and practices the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 3 residents (Resident #2 and Resident #3) reviewed for clinical records.1. The facility failed to ensure documentation was completed on the Individual Narcotic Record for Resident #2 by ADON and LVN B on 10/12/2025 and 10/20/25.2. The facility failed to ensure documentation was completed on the Medication Administration Record for Resident #3 by LVN C on 10/0/25These failures could place residents at risk for errors by staff when reading information in the clinical record that was inaccurate or incomplete.

Inspectors wroteBased on interviews and record reviews the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. If a child is admitted to the facility, the comprehensive care plan must be based on the child's individual needs. 1. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident#1's refusal of medication. 2. The facility failed to ensure a care plan was developed and implemented to address Resident #4 getting out from bed without assistance. This failure could place residents at risk for their mental and psychosocial needs not being met.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of medication 9 carts (300 hall medication cart) reviewed for storage. The facility failed to ensure the nurses medication cart for 300 hall was secured by a lock when it was left unattended by LVN A. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered- care plan, and the resident's choices for 1 (Resident #9) of 5 residents reviewed for quality of care. CNA N and CNA E on 08/04 25 identified a loose, abnormal arm while providing R#9 care and continued to provide care without communicating with the nurse. R#9 was not assessed for the abnormality several hours later after the CNA N remembered she had not reported the abnormality to the charge nurse. R#9 x-ray results: acute oblique displaced fracture of the distal humorous (upper arm bone) An Immediate Jeopardy was identified on 08/27/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 05:23 p.m. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 facility in that: The facility failed to have pest control effectively treat the facility for roaches and ants. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 5 residents (Resident #16) reviewed for consent for antipsychotic medications in that: Resident #16 was prescribed and administered Lorazepam (a psychotropic) without prior consent based on information of the benefits, risks, and options available. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts.

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 rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 5 residents reviewed for comprehensive care plans. 1. The facility failed to update Resident #10's oxygen order in his care plan. These failures could lead to residents not receiving needed care and/or consideration from staff as care is provided and/or receiving improper care/treatment. Findings Included: 1. Record review of Resident #10's admission record dated 08/3/2025 reflected a [AGE] year-old male with an admission date of 6/18/2025. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to review and revise comprehensive care plans after each assessment for 2 (Resident #10, Resident #4) of 8 residents reviewed for comprehensive care plan revisions. 1. The facility failed to review and revise Resident #10's comprehensive person-centered care plan for catheter use. 2. The facility failed to review and revise Resident #4's comprehensive person-centered care plan for insulin use. This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received assistance devices to prevent accidents for one (Resident #110) of three residents reviewed for transfers. CNA E failed to use a footrest to transfer Resident #110 from resident's room to shower room. The failure placed the residents, who required one or two people to assist with transferring, at risk for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 5 resident (Resident#91) reviewed for indwelling catheters. The facility failed to prevent Resident#91's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 5 (Resident #10 and Resident #13) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #10's oxygen was administered at the correct setting of 2 liters per minute on 08/3/2025 as ordered by the physician. 2. The facility failed to ensure Resident #13's oxygen was administered as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation and interview, the facility failed to ensure that diabetic equipment were stored in a locked compartment for 1 of 4 medication carts. The facility failed to ensure a (diabetic) lancet, sitting on top the unattended medication cart, was secured. This failure could place residents at risk of access or injury from a lancet.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated.2. The facility failed to ensure the DM's hands were washed and gloves was worn during the assistance of food preparation. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include:Observation of the kitchen counter on 08/03/25 at 9:20 AM revealed the following:1. 1 container of Thick-It (a brand of food and beverage thickener designed to help people with swallowing difficulties) covered with foil. Observation of the walk-in refrigerator on 08/03/25 at 9:26 AM revealed the following:1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #16) of 4 residents reviewed for medical records accuracy, in that: The facility failed to provide any documentation in the Progress Notes for Resident #16's from 01/31/2025 through 06/04/2025. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program which ensured standard and transmission-based precautions were followed to prevent the spread of infection, for 2 (Resident#39 and Resident #47) of 5 residents reviewed for infection control issues. 1. The facility failed to prevent family members from entering R#39's isolation room without donning PPE. 2. The facility failed to ensure the dressing on Resident #39's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. 3. CNA C failed to remove contaminated gloves after catheter care prior placing clean brief on Resident #47. These failures could place residents at risk of cross contamination and infection. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for wound care. LVN A failed to communicate and provide treatment for the Resident #1's skin tear. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 2 residents (Resident #1) reviewed for clinical documentation and medical records accuracy. The facility failed when Resident #1's June 2025 MAR order for Midodrine was inaccurately dated, as well as the ADON had never signed the MAR that Resident #1's Midodrine was administered on 06/13/2025. This deficient practice could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (Resident #1) of six residents reviewed for quality of care The facility failed to ensure WCN A treated Resident #1's wound on her left buttock per doctor's order. This failure had the potential to affect residents receiving wound care could experience infection, worsening of the wounds, and pain.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents observed for catheter use. Resident #1's catheter urine drainage port was draped over the side rail (above the body) restricting flow of urine to the collection bag. This failure could place residents who use cathethers at risk for potential complications or infections related to obstructed urine flow.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from neglect, for one of four residents (Resident #250) reviewed for neglect: CNA C stated she was aware Resident #250 required 2-person assistance with a bed bath but proceeded to give care to the resident alone resulting in the resident falling and fracturing her left femur. The non-compliance for Resident #250 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/15/2024 and ended on 03/15/2024. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of neglect resulting in serious injuries, harm, impairment, or death.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that the residents environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Residents #250) reviewed for accidents hazards and supervision. The facility failed to ensure Resident #250 was assisted by two care providers during a bed bath which resulted in her rolling out of bed onto the floor and sustaining a left femoral fracture. This failure could place residents at risk of accidents and injury. The non-compliance for Resident #250 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/15/2024 and ended on 03/15/2024. The facility corrected the non-compliance before the investigation began. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that the residents' right to review survey results were readily accessible to residents, family members and legal representatives of residents. For 1 of 1 survey books. The facility failed to make the results of the survey readily accessible for examination to residents and failed to post a notice of availability of the survey results. This failure could prevent residents from exercising their rights to view the survey results and the plan of correction.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessments for 1 of 3 residents reviewed for PASARR. The facility failed to ensure Resident #33 had an accurate PASARR Level 1 Screening which indicated a diagnosis of mental illness on 12/12/23. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #31), reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #31 addressing fall mat. These failures could affect residents by placing them at risk of not receiving the care and services for health promotion and continuity of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives grooming and personal care for 1 of 4 residents (#57) reviewed for ADL care. The facility failed to ensure Residents #57 was provided assistance with nail care. These failures could place residents at risk of scratches, infection, and loss of self-esteem.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident, for 1 of 6 residents (Residents #2) reviewed for baseline care plan, The facility failed to ensure Resident #2's baseline care plan included information related to the resident's full code status and the use of a Hoyer lift. This failure could affect newly admitted residents and place them at risk of not receiving appropriate interventions to meet their current needs and communication among nursing home staff to ensure their immediate care needs were met.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1), reviewed for care plans. Resident #1's comprehensive care plan dated 01/24/2024 incorrectly indicated she was a dialysis patient. The facility failed to ensure Resident #1's comprehensive care plan dated 01/24/2024 indicated she required a mechanical lift to transfer to and from bed. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 2 of 2 nutrition/supply rooms reviewed in that: There was unlabeled and undated food and beverages in both nutrition room refrigerators. The refrigerator temperature logs for both nutrition rooms were missing data. The room temperature logs for both nutrition rooms were missing data. These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness.

Inspectors wroteBased on observation, interview ad record review the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents ( Resident #35 and Resident #59) reviewed for call lights in that: Residents # 35, and # 59 were observed in their rooms with their call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two residents (Resident #60 and Resident #83) of twelve residents reviewed for care plans. 1. The facility failed to revise Resident #60's comprehensive person-centered care plan to reflect resident's weight loss and dietary plan. 2. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #83 to address physical therapy. This failure could affect residents who receive care at the facility and could result in missed or inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 (Resident #60) of 6 residents whose records were reviewed for weight loss in that: The facility did not monitor Resident #60's weight to identify a weight loss from 12/1/22 through 3/2/22. This failure could affect any resident and could result in residents' continued weight loss and decline in physical health.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident for 1 (Resident #13) of 5 residents reviewed medications, in that: The facility failed to clarify parameters for administering a blood pressure medication. This failure could place residents at risk for not receiving the therapeutic effects of the medications prescribed and/or received adverse effects from the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 (Resident #13) of 5 residents reviewed for labeling and storage, in that: The pharmacy label for Resident #13's prescription showed incorrect parameters for blood pressure. This failure could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications at the correct times.

Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #13) of 5 Residents reviewed for complete and accurate medication administration records, in that: The facility did not document physician ordered blood pressure readings for medication administration for Resident #13. This failure could place residents at risk for not receiving care and services and their medications as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections, hand hand hygiene procedures, and for establishing a process to make every visiitor entering the facility aware of suspected or confiremd SARS-COV-@2 infection for 1 of 1 staff (ADON) and one of four residents, (Resident #71) reviewed for infection control, in that: 1. The ADON removed sterile packing from its container with bare fingers. The ADON used non-sterile scissors to cut the packing. The ADON applied wound cleanser to sterile gauze in a non-sterile plastic cup. The ADON utilized non-sterile wooden spoons to apply ointments to an open surgical wound. 2. [...]