Windsor Place

F-F600 were noted and steps for removal were discussed. safety c. Incidents have been reviewed with plans to improve. Residents Affected - Few i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors.

d. Plan on Removal being conducted.

e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective'.

Interviews of nursing staff: on 2/28/2025 from 09:49 AM - 11:55 AM for( 6 AM - 6 PM shift) - DON, ADON, MDS Nurse, LVN C, CNA D, CNA E, CNA L, MA P, LVN Q, LVN W, LVN A, CNA AA

(6PM - 6AM shift) - MA X, LVN Y, LVN Z, CNA BB, CNA CC, CNA DD, CNA EE

Administrator, Dietary Manager, Assistant Dietary Manager, Housekeeping Supervisor, Social Worker, Maintenance Supervisor, Director Business Development, Medical Records, Dietary Aide H, Housekeeper K, Housekeeper M, Housekeeper N, Director of Rehabilitation, PTA U, OT V, Activities Assistant

During these interviews staff were able to correctly identify types of abuse such as physical, sexual, verbal and resident to resident altercations; who to notify if abuse was suspected - such as the abuse coordinator, physician, families; proper documentation in resident charts, incident reports and care plans; recognizing escalated behaviors such as increased screaming and agitation and notifying the physician immediately of escalating behaviors; ways to de-escalate behaviors 1 to 1 monitoring, redirecting, separating residents, removing residents from the environment, calming music, and social services.

On 02/28/2025 at 12:00 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facilities need to complete in-service training and evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 675755