ElderGrade

Inspection citations at Windsor Atrium

37 citations on record, 3 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 2 0
2025 17 1
2024 10 2
2023 8 0
D May 8, 2026 Tag F0842 Complaint investigation Corrected May 2026

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D May 8, 2026 Tag F0756 Complaint investigation Corrected May 2026

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

D December 9, 2025 Tag F0761 Complaint investigation Corrected Dec 2025

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D December 9, 2025 Tag F0656 Complaint investigation Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

E December 9, 2025 Tag F0842 Complaint investigation Corrected Dec 2025

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0880 Corrected Aug 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0842 Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0812 Corrected Aug 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0761 Corrected Aug 2025

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0695 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0690 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0689 Corrected Aug 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0657 Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0656 Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D August 29, 2025 Tag F0552 Corrected Aug 2025

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

E August 29, 2025 Tag F0925 Corrected Aug 2025

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

No actual harm, potential for more than minimal harm

J August 29, 2025 Tag F0684 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Immediate jeopardy to resident health or safety

D June 26, 2025 Tag F0684 Complaint investigation Corrected Jun 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D June 21, 2025 Tag F0842 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D August 21, 2024 Tag F0684 Complaint investigation Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D July 25, 2024 Tag F0690 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D June 27, 2024 Tag F0677 Corrected Jun 2024

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D June 27, 2024 Tag F0656 Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D June 27, 2024 Tag F0644 Complaint investigation Corrected Jun 2024

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

D June 27, 2024 Tag F0577 Corrected Jun 2024

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

No actual harm, potential for more than minimal harm

J June 27, 2024 Tag F0689 Complaint investigation Corrected Mar 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

J June 27, 2024 Tag F0600 Complaint investigation Corrected Mar 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Immediate jeopardy to resident health or safety

D May 9, 2024 Tag F0656 Complaint investigation Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D May 9, 2024 Tag F0655 Complaint investigation Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D April 6, 2023 Tag F0880 Corrected Apr 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D April 6, 2023 Tag F0842 Corrected Apr 2023

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D April 6, 2023 Tag F0761 Corrected Apr 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D April 6, 2023 Tag F0755 Corrected Apr 2023

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D April 6, 2023 Tag F0692 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D April 6, 2023 Tag F0656 Corrected Apr 2023

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D April 6, 2023 Tag F0558 Corrected Apr 2023

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E April 6, 2023 Tag F0812 Corrected Apr 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.