Inspection·April 17, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, interviews, and record reviews, the facility failed to implement a person-centered comprehensive plan of care for 2 of 4 residents reviewed for respiratory care services. (Resident #212 and #24) Findings include: 1.) Review of Resident #212's admission record documented diagnoses that included chronic respiratory failure, disease of pulmonary vessels, and chronic obstructive pulmonary disease (COPD). During an observation on 4/14/25 at 10:45 AM, Resident #212 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an observation on 4/15/25 at 8:30 AM, Resident #212 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an interview on 4/15/25 at 8:32 AM, Resident #212 stated, I have not changed my oxygen level. I need it to breath; it is my lifeline. Review of the resident centered comprehensive plan of care for Resident #212 read, [Resident name] is at risk for respiratory complications r/t [related to] chronic respiratory failure and COPD. Administer oxygen as ordered. Review of Resident #212's physician order dated 4/3/25 reads, Oxygen at 4 liters / min via Nasal Cannula. Humidification every shift for COPD. During an interview on 4/15/25 at 8:45 AM, Staff A, Licensed Practical Nurse stated, The oxygen is set at 3[liters], it should be 4 [liters], we check the levels throughout the day, I just haven't gotten to her yet. 2.) Review of Resident #24's admission record documented a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During an observation on 4/14/25 at 11:15 AM, Resident #24 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an observation on 4/15/25 at 7:30 AM, Resident #24 was observed lying in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. (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 3 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 04/17/2025 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)