Health 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 Page 1 of 2 105696 105696 10/03/2024 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0580 Level of Harm - Minimal harm or potential for actual harm member or legal representative when there is a change requiring such notifications. Circumstances requiring notification include: 1. Accidents a. Resulting in injury, b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . 4. A transfer or discharge of the resident from the facility. Residents Affected - Few 105696 Page 2 of 2