Inspection·October 3, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's physician and resident's representative were notified of a change in condition for 1 of 3 residents reviewed for change in condition, Resident #1. Findings include: Review of Resident #1's admission record showed the resident was admitted on [DATE] with the diagnoses to include encephalopathy, muscle weakness, anemia, dementia, and osteoporosis. During an interview on 10/3/2024 at 10:47 AM with the Director of Nursing (DON), review of the facility's documentation showed on 9/15/2024 at 11:30 AM Resident #1 was found on the floor with a knot on the left side of head, and the resident had previous fall on 9/13/2024 at around 3:00 PM. Review of nursing progress notes for 9/15/2024 did not contain documentation that Resident #1's physician or representative was notified of the resident's fall and injury. Review of Resident #1's hospital transfer form dated 9/16/2024 at 7:45 AM read, s/p [status post] fall x 2. During an interview on 10/3/2024 at 3:07 PM, Staff A, Registered Nurse (RN), stated, I was taking care of the resident [Resident #1] and I thought that [Staff B, LPN's name] called the doctor and family member. I did not call the doctor or the family. During an interview on 10/3/2024 at 3:20 PM, Staff B, LPN, stated, I was getting off of shift and did not call the doctor or the family. [Staff A, RN's name] was the resident's nurse and I thought he called the doctor and family. During an interview on 10/3/2024 at 3:44 PM, the DON stated, The doctor and the family are to be notified of any change in condition and an additional fall is a change in condition. No call was placed to the doctor or to the family to inform of the fall on 9/15/2024. Review of the facility policy and procedure titled Notification of Changes revised in January 2024 read, 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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105696 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 10/03/2024 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)