Health 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. Page 1 of 3 105696 105696 04/17/2025 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #24's physician order dated 3/18/24 reads, Oxygen at 3 liters/minute via nasal cannula every shift related to Chronic Obstructive Pulmonary Disease. Review of the comprehensive plan of care for Resident #24 dated 4/4/25 reads, Resident is at risk for respiratory complications r/t [related to] chronic respiratory failure and COPD. Administer oxygen as ordered. During an interview on 4/16/25 at 9:05 AM, the Director of Nursing stated, We should always follow the physicians orders, and the care planned interventions when running oxygen. Review of the policy titled, Oxygen Administration with a review date of 1/21/2025 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 105696 Page 2 of 3 105696 04/17/2025 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

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 ensure that respiratory care and services were provided consistent with professional standards of practice for 2 of 4 Residents (Resident #212 and Resident #24). Residents Affected - Few Findings include: Review of Resident #212's admission record documented a diagnosis 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 Resident #212's physician order dated 4/3/25 reads, Oxygen at 4 liters / min [minute] 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. 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. During an interview on 4/15/25 at 8:32 AM, Resident #24 stated, I do not know how to change my O2 [oxygen] level. If I have trouble breathing, I call the nurse. Review of Resident #24's physician order dated 3/18/24 reads, Oxygen at 3 liters/minute via nasal cannula every shift related to chronic obstructive pulmonary disease. During an interview on 4/17/25 at 8:30 AM, the Director of Nursing stated, Oxygen should be running at the physician ordered rate. Nurses should check the levels when giving meds [medications]. Review of a policy titled, Oxygen Administration with a review date of 1/21/2025 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 105696 Page 3 of 3