Inspection·February 1, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm has been using a C-PAP, but the staff come in the evening and put water in the C-PAP and help her get in on her face and she sleeps with it every night. Review of Resident #31's admission record documented an admission date of 12/5/20 with diagnoses that included congestive heart failure and obstructive sleep apnea. Residents Affected - Few Review of Resident #31's physician's orders dated 11/14/23 read, CPAP setting 8.0 cmH20 [centimeter of water] at bedtime related to obstructive sleep apnea. Review of Resident #31's care plan dated 9/22/23 and revised on 11/16/23 documented Resident exhibits or is at risk for respiratory complications R/T (related to) respiratory distress due to OSA (obstructive sleep apnea) with interventions that include C-Pap as ordered for OSA. Review of Resident #31's Minimum Date Set (MDS) Quarterly assessment dated [DATE], Section O, Special Treatments, Procedures, and Programs documented Resident #31 used a non-invasive mechanical ventilator but the type of ventilator support [CPAP] was left unchecked. During an interview on 1/31/24 at 9:43 AM, the MDS Coordinator, RN, stated, the coding was a mistake due to incorrectly documenting non-invasive mechanical ventilator which disabled further questioning for a CPAP. She confirmed that the Quarterly MDS assessment dated [DATE] was inaccurate. Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual reads O0110G3. C-PAP. Check if the non-invasive mechanical ventilator support was CPAP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 2 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that residents who required blood glucose monitoring receive treatment in accordance with professional standards of practice for 1 of 3 residents review for insulin administration (Resident #77) and failed to promptly notify a physician for critical high laboratory results for 1 of 3 resident reviewed for laboratory results ( Resident #108) Residents Affected - Few Findings include: Review of the admission record for Resident #108 documented diagnosis that include essential primary hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, hypothyroidism, unspecified atrial fibrillation, unspecified protein calorie malnutrition, dysphagia, adult failure to thrive, and chronic kidney disease. Review of the physician's order dated [DATE] reads, CBC (complete blood count), CMP (complete metabolic profile), serum magnesium, prealbumin every night shift for failure to thrive for 1 day. Review of the Lab results report for Resident #108 dated [DATE] reads, Collection date [DATE] at 6:35 AM, received date [DATE] at 11:19 AM, reported date [DATE] at 1516 (3:16 PM) Comprehensive Metabolic Panel: Critical result called to [Staff name] on [DATE] 3:04 PM by [Laboratory Staff name] Results were read back to caller. Sodium 156 meq [milliequivalent/l (liter)]. Review of the nursing progress notes for Resident #108 from [DATE] through [DATE] documented no progress notes indicating call to physician or nurse practitioner for notification of critical lab results. Review of the physician's order for Resident #108 dated [DATE] reads, Stat BMP (basic metabolic profile), CBC for hypernatremia (high sodium levels). Review of the physician's order for Resident #108 dated [DATE] reads, May insert IV (intravenous catheter). Review of the physician's order for Resident #108 dated [DATE] reads, Dextrose Intravenous Solution 5% use 2 liters intravenously every shift for abnormal labs d/c (discontinue) when complete. During an interview on [DATE] at 9:55 AM the Director of Nursing (DON) stated, I don't know why the critical lab wasn't called. I was not aware of this. All critical labs should be called immediately. I was not told that the nurse practitioner had any concerns about him or that we didn't call him about these. I don't see documentation that anyone was informed of these results before the 27th [[DATE]]. We should have called them immediately. During an interview on [DATE] at 10:19 AM, the Advanced Nurse Practitioner (APRN) stated, I was not called about these lab results, they were not called to anyone. I expect all critical labs should be called. I was displeased that was not dealt with. In hypernatremia you would expect progressive altered mental status declines and that is what I was seeing on that day. I saw him [Resident #108], I wanted the labs immediately rechecked and it [the sodium level] was the same and so I started the fluids. It is unlikely that it would have corrected itself. But I still wanted to recheck it. His diagnosis was failure to thrive, I spoke to nephew as POA (power of attorney), his sister [the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 3 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm resident's] had recently died and he was declining and got very depressed and was giving up. The hypernatremia was likely a result of dehydration and insufficient intake. They gave the 2 liters of fluid. I should have been notified on the 25th when the critical lab came in. It was a delay in his treatment, but I can't say whether it would have altered his course. I know with the recheck of the sodium it had not worsened; it was still 156. Residents Affected - Few 2. Review of the admission record for Resident #77 documented diagnosis that included type 2 diabetes mellitus, essential primary hypertension, diverticulosis, neoplasm of ovary, cholelithiasis, fatty liver, acute kidney failure, and hyperlipidemia. Review of the physician's order for Resident #77 dated [DATE] reads, Humalog KwikPen 100 units/ml (milliliter) solution pen injector. Inject as per sliding scale; if 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 352-400 = 10 units, 401-450= 12 units. Notify provider if greater than 450, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for [DATE] through [DATE] documented on [DATE] at 4:30 PM a blood sugar of 488 with a chart code 9. Chart code 9 = Other / See progress notes. Review of the nursing progress notes for [DATE] document no progress note or physician notification of the elevated blood sugar. During an interview on [DATE] at 9:30 AM, the Director of Nursing (DON) stated, All physician orders should be followed, and they all should be documented correctly. They should have called the 488 [blood sugar to the doctor] and documented that they did. During an interview on [DATE] at 10:15 AM, the APRN stated, I was not aware that the blood sugar was 488 and was not called about it. I may have added additional insulin had I been called. During an interview on [DATE] at 8:45 AM, the Medical Director stated, I was not notified of a blood sugar of 488. They should have done that. Review of the policy and procedure titled Notification of Changes last review date of [DATE] reads, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial conditions such as deterioration and health, mental or psychosocial status. This may include: a. Life threatening conditions or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 4 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to administer oxygen according to physician's orders and professional standards of practice for 2 of 4 residents reviewed for respiratory care. (Resident #82 and #30) Residents Affected - Few Findings include: Review of Resident #82's admission record documented diagnosis that included acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, emphysema, nicotine dependence, non ST elevation myocardial infarction, fibroblastic disorder, and rheumatoid arthritis. Review of Resident #82's physician's order dated 11/22/2023 reads, Oxygen at 6 L (liters) N/C (nasal cannula) continuous with humidification. During an observation on 1/29/2024 at 12:46 PM Resident #82 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 4 liters per minute. During an interview on 1/29/2024 at 12:46 PM Resident #82 stated, I have not changed my oxygen level. I need it set at 6 liters and don't change it myself. During an observation on 1/31/2024 at 8:36 AM Resident #82 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 4 liters per minute. During an interview on 1/31/2024 at 2:10 PM Staff D, Registered Nurse stated, The oxygen is set at 4, it should be 6 liters, maybe he changed it. I should check on the amount running when I give meds [medications]. During an interview on 1/31/2024 at 4:05 PM the Director of Nursing stated, Oxygen should be running at the physician ordered rate. Nurses should check when giving meds. 2. Review of Resident #30's admission record documented diagnosis that include chronic obstructive pulmonary disease, age related osteoporosis, iron deficiency anemia, major depressive disorder, and anxiety disorder. Review of the physician's order for Resident #30 dated 7/16/2023 reads, Oxygen at 2 liters/minute via nasal cannula every shift related to COPD (chronic obstructive pulmonary disease). During an observation on 1/29/2024 at 9:31 AM, Resident #30 was observed sleeping in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters per minute. During an observation on 1/30/2024 at 7:43 AM, Resident #30 was observed sleeping in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters per minute. During an interview on 1/31/2024 at 2:15 PM, Staff D, RN stated, Her oxygen should be at 2 liters. I think maybe she turned it up. I have not checked it until now. No oxygen policy and procedure was provided prior to exit from facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 5 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observations, interviews, and record review, the facility failed to label and store medications according to professional standards of practice in 2 of 4 medication carts. Findings include: During an observation of medication cart #1 with Staff E, Licensed Practical Nurse (LPN) on 1/29/2024 at 9:05 AM, there was one medication cup that contained 11 medications which had no resident identifier and no indication of what the medications were. One opened bottle of artificial tears with no opened date or expiration date. During an interview on 1/29/2024 at 9:10 AM, Staff E, LPN stated, I just left those pills in the cart because the resident was not in their room. The eye drops should be dated. During an observation of medication cart #3 with Staff F, LPN on 1/29/2024 at 9:22 AM, there was one medication cup in the drawer that contained 13 pills which had no resident identifier and no indication of what the medications were. There was one opened bottle of Dorzolamide ophthalmic solution with no opened date or expiration date. During an interview on 1/29/2024 at 9:28 AM, Staff F, LPN stated, That resident was not available right now, I shouldn't have left them, they should be labeled. I can't tell when the eye drops were opened. During an interview on 1/29/2024 at 1:30 PM, the Director of Nursing stated, All medications should be labeled. Review of the policy and procedure titled, Labeling of Medications and Biologicals last reviewed date 1/23/2024 reads, Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 2. Medication labels must be legible at all times. 4. Labels for individual drug containers must include: a. The resident's name; c. The medication name. h. The expiration date when applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 6 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in 2 of 2 nourishment areas. Findings Include: A tour of the facility nourishment rooms was completed on 1/29/24 beginning at 9:48 AM with the Certified Dietary Manager (CDM). On 1/29/24 at 10:15 AM in the east nourishment room freezer there was an opened, unlabeled, undated container of Mystic Bahama Blueberry drink, an unlabeled, undated ½ eaten bar of a chocolate [NAME] Daz Ice cream on a stick, 3 bags of unlabeled, undated brown frozen bananas, 1 unlabeled, undated cheddar broccoli casserole, 2 unlabeled Styrofoam cups filled with an unidentifiable substance, and there was a reddish-brown sticky substance on the interior of the freezer bottom shelf. On 1/29/24 at 10:30 AM in the west nourishment room there were 11 pudding cups with an expiration date of 1/25/24 written in blue ink on the lid, there were 10 applesauce cups with an expiration date of 1/25/24 written in black ink on the lid, there was one unlabeled, undated piece of Chocolate pie with whipped topping on the top shelf of the refrigerator. In the bottom left drawer of the refrigerator there was 1 Taco Bell paper bag undated and unlabeled with an unidentifiable substance inside. There was a brownish sticky substances on the top and bottom glass shelves of the refrigerator, and on the bottom shelf of the refrigerator door (Photographic Evidence Obtained). On 1/29/24 at 10:45 AM during an interview Staff C, Licensed Practical Nurse, Unit Manager stated, It is the certified nursing assistant's responsibility to keep the nourishment rooms clean. Sometimes the house keepers will tidy it up, and Dietary is responsible for the cleaning of the refrigerators and freezers. On 1/29/24 at 10:15 AM during an interview, the CDM stated, The nursing staff is responsible for cleaning the nourishment rooms, dietary will stock the items, and remove the expired items. I expect the Dietary staff to go and check those rooms daily, and wipe down anything that needs it. Review of the policy and procedure titled Use and Storage of Food Brought in by Family or Visitors with a reviewed date of 1/23/24 reads, Policy: It is the right of the resident of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Policy Explanation and Compliance Guidelines: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and date. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. B. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. Review of the policy and procedure titled Refrigerators and Freezers with a review date of 1/23/24 reads, Policy Statement. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation. 10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Pantry refrigerators/freezers should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 7 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 be monitored by all facility staff and cleaned at least daily and more often as necessary. Level of Harm - Minimal harm or potential for actual harm A cleaning schedule for the nourishment rooms was requested, information was not provided. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 8 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, record review and review of the facility policy and procedure the facility failed to accurately and completely document within the medical record for 2 out of 3 residents reviewed for insulin administration (Resident #77 and #95). Findings include: Review of the admission record for Resident #77 documented diagnosis that included type 2 diabetes mellitus, essential primary hypertension, diverticulosis, neoplasm of ovary, cholelithiasis, fatty liver, acute kidney failure, and hyperlipidemia. Review of the physician's order for Resident #77 dated 9/26/2023 reads, Humalog KwikPen 100 units/ml (milliliter) solution pen injector. Inject as per sliding scale; if 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 352-400 = 10 units, 401-450= 12 units. Notify provider if greater than 450, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Review of the physician's orders for Resident #77 dated 12/7/2023 reads, Lantus Solostar subcutaneous solution pen-injector 100 unit/ml (milliliter) (insulin glargine) inject 30 unit subcutaneously one time a day for T2DM (type 2 diabetes mellitus). Review of the Medication Administration Record (MAR) for Resident #77 dated 12/1/2023 through 12/31/2023 documented no blood sugar recorded on 12/23/2023 at 6:30 AM and 12/25/2023 at 6:30 AM. Both of these dates and times were blank. Review of the MAR for Resident #77 dated 1/1/2024 through 1/31/2024 Staff B, LPN documented on 1/16/2024 at 9:00 PM chart code 4 and no blood sugar was documented. Chart code 4 = Vitals outside parameters for administration. During an interview on 2/1/2024 at 8:15 AM, the Director of Nursing (DON) stated, All blood sugars should be documented. I don't know why they aren't. All documentation should be accurate. The nurse did call the doctor and got orders to hold the insulin. During an interview on 2/1/2024 the Medical Doctor (MD) stated, I was called each time that the insulin was held. 2. Review of the admission record for Resident #95 documented diagnosis that included unspecified open wound, left foot, occlusion stenosis of right anterior cerebral artery, hemiplegia affecting left dominant side, essential primary hypertension, unspecified atrial fibrillation, osteomyelitis, hyperlipidemia, cerebral infarction, and type II diabetes mellitus with hyperglycemia. Review of the physician's order for Resident #95 dated 8/11/2023 reads, Lantus Solostar 100 unit/ml (milliliter) solution pen-injector Inject 20 unit subcutaneously one time a day related to type 2 diabetes mellitus with hyperglycemia. Review of the MAR for Resident #95 dated 12/1/2023 through 12/31/2023 staff documented on 12/19/2023 at 6:30 AM 'chart code 4 for Lantus 20 Units subcutaneously. Blood sugar was documented as 134. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 9 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Chart code 4 = Vitals outside of parameters for administration. Level of Harm - Minimal harm or potential for actual harm Review of the nursing progress notes for Resident #95 documented no progress notes related to holding insulin or physician notification on 12/19/2023. Residents Affected - Few Review of the MAR for Resident #95 dated 1/1/2024 through 1/31/2024 staff documented on 1/7/2024 at 6:30 AM chart code 4 for administration of Lantus 20 units subcutaneously. Blood sugar was documented as 108, on 1/8/2024 at 6:30 AM Staff documented chart code 4 with no blood sugar documented, and on 1/11/2024 at 6:30 AM Staff B, LPN documented chart code 9 with no blood sugar documented. Chart code 4 = Vitals outside of parameters for administration, Chart code 9 = Other/see progress notes. Review of the nursing progress notes for Resident #95 from 1/7/2024 through 1/12/2024, there were no progress notes related to holding insulin or physician notification. During an interview on 2/1/2024 at 8:15 AM, the Director of Nursing (DON) stated, All blood sugars should be documented. I don't know why they aren't. All documentation should be accurate. The nurse did call the doctor and get orders to hold the insulin. During an interview on 2/1/2024 the Medical Doctor (MD) stated, I was called each time that the insulin was held. Review of the policy and procedure titled Medication Administration last reviewed date of 1/23/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination for infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 11. Compare medication source (bubble pack, vial, etc). with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 14. Administer medication as ordered in compliance with manufacturers specifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 10 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to perform hand hygiene during medication administration in 2 out of 5 observations consistent with accepted standards of practice. Residents Affected - Few Findings include: During an observation of medication administration for Resident #78 conducted on 1/31/2024 at 8:31 AM, Staff D, Registered Nurse (RN) did not perform hand hygiene when returning from room and returning to the medication cart. Staff D unlocked medication cart, poured medications, entered Resident #78's room, checked blood pressure, and administered all medications. Staff D, RN exited the resident's room without performing hand hygiene and returned to the medication cart. During an observation of medication administration for Resident # 82 conducted on 1/31/2024 at 8:36 AM, Staff D, RN did not perform hand hygiene and prepared the residents medications, locked the medication cart, entered Resident #82's room without performing hand hygiene and administered medications. Staff D, RN exited the room and without performing hand hygiene began preparing medications for another resident. During an interview on 1/31/2024 at 12:30 PM Staff D, RN stated, Oh, I did not use hand sanitizer or wash my hands. I should have. During an interview on 1/31/2024 at 12:55 PM, the Director of Nursing (DON) stated, All staff should perform hand hygiene when giving medications. Review of the policy and procedure titled Medication Administration last reviewed date of 1/23/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination for infection. Policy Explanation and Compliance Guidelines: 4. Wash hands prior to administering medications per facility protocol and product. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Review of the policy and procedure titled Hand hygiene last reviewed date of 1/23/2024 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. Hand hygiene table: before preparing and handling medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 11 of 12 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105696 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to maintain equipment to be in a safe operating condition for 1 reach in refrigerator in the main kitchen. Residents Affected - Few Findings include: On 1/29/24 at 9:30 AM during the initial tour of the main kitchen with the Certified Dietary Manager (CDM), an observation of the seal (gasket) was noted to be falling off of the top right-hand corner, and down the right side of the reach in refrigerator. The refrigerator was noted to have 8 oz milk cartons, Ensure nutritional supplements, vanilla pudding, and various juices sitting on the shelves. There was a thermometer that read 40 degrees in the back of the refrigerator. During an interview on 1/29/24 at 9:30 AM with the CDM, she stated, I'm not gonna [going to] hide it, the seal had just come off a couple of days ago, and the new one is on order I think. Review of a purchase order for an Arctic Air Refrigerator was obtained on 1/30/24 that showed an order was submitted on January 29, 2024 at 4:49 PM by the Maintenance Director. The purchase is pending approval. During an interview on 1/31/23 at 10:30 AM the Maintenance Director stated, I only keep work logs relating to the compressors on the refrigerators. The dietary department would keep the logs on the upkeep of the gaskets. On 1/31/23 at 12:30 PM, a request was made for the logs relating to gasket condition of the facilities refrigerators. The information was not provided. Review of the policy and procedure titled Refrigerators and Freezers with a review date of 1/23/24 reads, Policy Statement. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation. 9. Culinary Service Manager will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105696 If continuation sheet Page 12 of 12