Windsor Atrium

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Aug 29, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Jun 27, 2024

  47828 Based 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. […]

• Immediate jeopardy, isolatedF689Jun 27, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF678Jul 2, 2021

  Based on interview and record review, the facility failed to ensure that a resident's CPR/advance directive/physician orders were followed for 1 (Resident #1) of 6 residents reviewed for CPR, in that: LVN A found Resident #1 unresponsive and LVN A told RN B. Both LVN A and RN B failed to check Resident #1's code status, which was a full code, causing a delay in resuscitation. The resident expired in the facility. The facility failed to ensure staff were trained on how to locate a resident's code status. This failure could affect residents with advance directives and physician orders in place. An Immediate Jeopardy was identified to have occurred from [DATE] to [DATE]. […]

• No harm, potential for more than minimal, patternF842Dec 9, 2025

  Based 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.Findings include:1. […]