Health inspection·September 30, 2022

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident had a right to secure and confidential personal and medical records for one Resident (#85) of five residents reviewed for medical record confidentiality. Residents Affected - Few LVN E failed to ensure confidential and medical information were kept private for Resident #85. This deficient practice placed residents at risk of loss of privacy and dignity and decreased quality of life. Findings included: Record review of Resident #85's face sheet dated 09/29/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses of: dementia, diabetes mellitus, hypertension (high blood pressure), and muscle wasting. Observation of 09/28/22 at 7:45 AM of the 200 Hall medication nurse cart revealed the cart was unlocked and not attended to by any staff. The computer screen displayed Resident #85's Medication Administration Record which this surveyor, another surveyor and an unknown female visitor saw while approaching and/or passing by the screen. The screen was easy to read when passing in front of it. At 7:47 AM, LVN E opened the door, walked out of Resident #85's room, which was located across from her medication cart and cleared the computer screen. Interview with LVN E on 09/28/22 at 07:47 AM revealed she said the computer screen should be locked and not dispaying any resident records when not using it to protect the resident's privacy and confidentiality. LVN E said she was aware of the Health Information Protection laws and was re-trained on the laws upon her employment at the facility approximately 10 months ago. Interview with the Director of Nurses (DON) and the Administrator on 09/30/22 at 08:53 AM revealed the DON said all resident medical records were confidential. The DON said staff were to lock their computer screens when not in use in order to prevent resident medical information from being exposed. The DON and the Administrator said they conducted rounds daily, throughout the day, to check for locked computer screens and locked medication carts. Record review of the facility's undated Resident Rights admission Packet documented Our Responsibilities: In addition to providing you your rights, as detailed above, the federal privacy standard requires us to: Page 1 of 18 676321 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0583 Level of Harm - Minimal harm or potential for actual harm -Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information . -Train our personnel concerning privacy and confidentiallity . Residents Affected - Few 676321 Page 2 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 2 Residents (#82 and #84) of 24 residents reviewed for care plan revision, in that: Resident #84 care plan was not reviewed or revised after the quarterly MDS assessment dated [DATE]. These failures could place residents at risk for inadequate care. The findings included: Resident #82Record review of Resident # 82 admission record dated [DATE] documented a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] after hospitalization with a diagnosis of: Cerebral Infarction, unspecified (a pathologic process that results in an area of necrotic tissue in the brain); Paroxysmal Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat).; Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) following Cerebral Infarction affecting Left Non-Dominant Side. The admission record also indicated Resident #82 advance directive as Do Not Resusitate. Record review of Care Plan for Resident # 82 dated [DATE] revealed the resident is a FULL CODE (If a person's heart stopped beating and/or if they stopped breathing, all resuscitation procedures would be provided to keep them alive) with interventions to provide cardiopulmonary resuscitation and to mark chart and all pertinent documents with FULL CODE. Record review of Resident # 82 electronic medical record included a physician's order dated [DATE] which stated Do Not Resuscitate. Further review of the orders in the electronic medical record included a physician's order dated [DATE] which stated Admit to Hospice. Record review of Resident # 82's Minimum Data Set, dated [DATE] revealed a brief interview of mental status could not be conducted due to moderately impaired cognitive skills for daily decision making. Resident # 82 required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene On [DATE] at 04:16PM an interview was conducted with Minimum Data Set coordinators LVN K, LVN I and DON regarding Resident # 82 Care Plan. LVN I stated the most current care plan available is [DATE] and the care plan was due on [DATE]. LVN I did not give a verbal response and shook head no as to the reason the care plan was not completed. LVN I stated yes the resident had a significant change since the last care plan was completed and agreed that a care plan revision would have been warranted following the resident's significant change and a care plan revision was not completed. LVN I stated the resident has a Do Not Resuscitate order in place, which is correct and the reason why resident is a Full Code remains in the Care Plan is that the Care Plan was not updated. LVN K states the consequence of not having the correct information on the Care Plan is that the patient could receive chest compressions at end of life which would go against his wishes. 676321 Page 3 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with LVN G, Charge Nurse for Resident # 82, on [DATE] at 11:17AM. LVN G stated Resident #82's most current Care Plan is dated [DATE]. The Care Plan indicated that the resident is a FULL CODE. LVN G went on to state that the resident had recently went to the hospital and came back and stated, I thought he was on hospice. After reviewing the orders, LVN G stated resident had an order to DO NOT RESUSCITATE dated [DATE]. LVN G stated he, did not ever look at the Care Plan, that is mainly for dietary and activities and that the information regarding the residents could be found on the resident's profile in the electronic medical record. LVN G also indicated, in an emergent situation, he would not look at the Care Plan, he would look at the profile in the electronic medical record, which indicated Do Not Resusitate. LVN G stated the consequence of not having an updated Plan of Care could result in the resident receiving incorrect care. R#84Record review of Resident # 84 face sheet dated [DATE] documented a [AGE] year-old female admitted on [DATE] with a diagnosis of Alzheimer's disease, Cerebral infarction (stroke), Insomnia (sleeplessness), Type II Diabetes, Hyperlipidemia (excess lipids), Hypertension (high blood pressure). A record review of Resident #84's Quarterly Minimum Data Set, dated revealed she had a brief interview of mental status score of 11, indicating moderate cognitive impairment. Resident #84 care plan was not reviewed or revised for a quarterly MDS assessment with a review date of [DATE]. During an interview with Ombudsman on [DATE] at 10:00 AM she stated the facility is attempting to discharge Resident #84 for falls. During an interview on [DATE] at 10:39 AM Resident #84 stated she had a fall a couple of weeks ago. During an interview with LVN I on [DATE] at 3:30 PM she stated: So, I look at the care plan often, it looks like I missed it. Her (Resident # 84) care plan was up for review. I haven't done the annual update yet. It was supposed to done in July, but it didn't happen. I am aware that the facility wants to discharge her, but the care plan does not reflect that. The care plan from [DATE] does not have a one-to-one requirement for the resident for falls. I should have a care plan in there. There are repercussions. If the staff does not see it, then they don't know. She could get hurt and fall if they don't know. During an interview with DON on [DATE] at 3:30 PM she stated: So, ahh Resident #84, entrance [DATE] (BIMS of 11 indicating moderate mental impairment), is, was a nurse .she has had several falls, and I try to put interventions in place after each fall. The interventions are not put in the care plan. We will make an updated care plan for her. I missed it. It will be done today. During an interview with LVN R on [DATE] at 3:30 PM she stated: the resident has fallen after the care plan has expired. A care plan was not revised after a fall. Record review nurses note: 676321 Page 4 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] 10:13 NURSING - Nurse Note Note Text: Resident #84 resting in room and continues on 1:1 care when family not present. When exiting room resident laughs and states I don't need anyone here to watch me resident noncompliant with asking staff for assistance with transfers and spoke to resident of why 1:1 care in place for safety, resident laughs. Will continue to monitor. [DATE] 01:13 Orders - General Note from eRecord Note Text: Resident #84 is sleeping at present, with no signs of discomfort and no behaviors noted. Resident continues on 1/1 r/t falls due to noncompliance and behaviors. Resident is toileted every 2 hrs or as needed. Resident is reminded to use call light to call for staff assistance with transferring and ambulating with walker. Call light remains within resident's reach. Will continue to monitor and educated on call light use, for alerting staff for assistance. During an interview with the DON on [DATE] @ 10:20 AM she stated the facility care plan policy and procedures guide did not have references for quarterly or annual re-assessment requirements. 676321 Page 5 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two Residents (#34 and #-83) of two residents reviewed with indwelling urinary catheters received the appropriate treatment and services to prevent Urinary Tract Infection (UTI's): 1. The facility failed to ensure Resident #34's indwelling urinary catheter drainage bag and tubing was kept off the floor and had the catheter tubing anchored to her thigh to prevent the tubing from pulling. 2. The facility did not ensure Resident #83's urinary catheter and tubing were secured. This deficient practice could affect any resident with an indwelling urinary catheter, without physician's orders at risk for not receiving proper catheter care and/or development of UTI's. The findings included: 1. Record review of Resident #34's face sheet dated 09/29/22 documented a [AGE] year-old female admitted [DATE] with the diagnoses of: urinary tract infection and obstructive uropathy (occurs when urine cannot drain through the urinary tract and backs up into the kidney and causes the kidney to become swollen). Record review of Resident #34's comprehensive care plan dated 05/11/22 documented ·The resident has a Urinary Tract Infection; ·The resident has Indwelling Catheter: Obstructive Uropathy .Interventions: CATHETER: .Position catheter bag and tubing below the level of the bladder and away from entrance room door; CATHETER: Change catheter every month and as needed; Check tubing for kinks each shift; Monitor for signs and symptoms of discomfort on urination and frequency. Record review of Resident #34's Quarterly Minimum Data Set, dated [DATE] revealed she had clear speech, made herself understood, understood others, and had a brief interview of mental status score of 3severe cognitive impairment. Resident #34 required extensive assistance with one-person physical assist for bed mobility, transfers, dressing, and personal hygiene. Record review of Resident #34's September 2022 physician orders documented Foley Catheter (a thin, flexible catheter used especially to drain urine from the bladder by way of the urethra): Change 18 French with 10 milliliter bulb as needed for Obstructive Uropathy; Check Foley catheter every shift for placement. May use leg strap to secure Foley in place. Observation and interview of Resident #34 on 09/28/22 at 08:18 AM revealed she was lying in a low bed. Resident #34 had an indwelling urinary catheter drainage bag that rested on the floor of the right side of her bed. The drainage bag was in a blue privacy bag however, the top aspect of the indwelling urinary drainage bag was out of the privacy bag which had contact on the floor and the drainage bag tubing also rested on the floor. CNA D picked up the bag from the floor, adjusted it so that the entire drainage bag was in the privacy bag, and placed the bag in a grey basin. 676321 Page 6 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with CNA D on 09/28/22 at 8:20 AM revealed she said the urinary drainage bags were not to touch the floor because the floor was dirty and that could place the resident at risk for infection. CNA D said she walked in the room and saw the bag on the floor so I corrected the problem by putting the bag in a basin since her bed was in a low position. CNA D said it was the responsibility of all nursing staff caring for Resident #34 to ensure her indwelling urinary drainage bag was not touching the floor. CNA D said she would inform Resident #34's nurse. Interview with LVN H on 09/28/22 at 11:44 AM revealed he was informed by CNA D that Resident #34's indwelling urinary catheter drainage bag was on the floor. LVN H said Resident #34 did not like the catheter and usually moved its position, sometimes dropping it on the floor. LVN H said he did not notice if Resident #34's catheter drainage bag was on the floor when he initially saw Resident #34 at the beginning of his shift because he was focused on her oxygen supplement. LVN H said he and CNA D should Always be monitoring the position of the drainage bag. LVN H said it was important to keep the drainage bag off the floor to prevent infection and accidents. Observation and interview with Resident #34 on 09/29/22 at 09:19 AM revealed she was lying in bed calling out for CNA G who was assisting Resident #34's roommate. At 9:30 AM, CNA G provided Resident #34 with incontinent care. While Resident #34 received incontinent care, it was observed that Resident #34's catheter tubing was hanging off the bed, pulled tight and stretched downward. Resident #34 did not have any device anchoring/securing her catheter tubing from pulling. Resident #34 said she could feel the catheter tubing pulling and it was uncomfortable. Resident #34 said she had not had anything placed on her thighs to hold her catheter tubing in place. Interview with CNA G on 09/29/22 at 9:35 AM revealed she said Resident #34 should have had a catheter holder attached to Resident #34's leg to prevent the tubing from pulling. CNA G said she and the nurse were responsible for ensuring a holder was in place. CNA G said it was first known to her that Resident #34 did not have a catheter holder at the time she changed Resident #34. CNA G said she would retrieve a holder and put it on Resident #34 and inform her nurse. CNA G said the catheter holder was used to prevent the catheter tubing from being pulled out and injury. Interview with LVN H on 09/29/22 at 9:38 AM revealed he said he did not know Resident #34 did not have a leg strap to hold her urinary catheter tubing. LVN H said leg straps were used to keep the catheter tubing in place, to keep the tubing from pulling or tugging which could cause discomfort, pain or injury. LVN H said it was the responsibility of the nurse and nurse aide to monitor that the leg strap was in place. LVN H said Resident #34 was Notorious for taking the leg strap off and hiding it or putting it under her pillow. LVN H said it was important for Resident #34 to have her catheter tubing anchored to prevent the catheter from being pulled out and prevent injury. 2. Record review of Resident #83's face sheet dated 12/03/21 revealed an [AGE] year-old female admitted on [DATE] with medical diagnoses of dementia, diabetes, heart failure, high blood pressure, acid reflux, kidney disease, obstructive and reflux uropathy (uterovaginal prolapse, when the uterus drops down to the vagina), arthritis, asthma, muscle weakness, lack of coordination, and anxiety. Record review of Resident #83's care plan dated 12/03/21 documented: Focus: The resident has a foley Catheter date Initiated: 12/03/21 Goal: The resident will be/remain free from catheter-related trauma through the review date. Date Initiated: 12/03/2021 Revision on 03/24/2022 Target Date: 07/24/2022. Interventions: 18 FR 30 ml foley catheter o Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 676321 Page 7 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0690 Level of Harm - Minimal harm or potential for actual harm 04/27/2022 Revision on 04/27/2022 o Check tubing for kinks each shift. Date Initiated: 03/24/2022 Revision on 03/24/2022 o Monitor/document for pain/discomfort due to the catheter. Date Initiated: 03/24/2022 o Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns date initiated 03/24/22. Residents Affected - Few Record review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed: -BIMS of 5 = Severe cognitive impairment -required extensive two-person physical assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. -had an indwelling catheter. Record review of Resident # 83's physician orders dated 12/03/21 documented an order to check foley catheter every shift for placement. May use leg strap to secure foley in place. An observation on 09/27/22 at 2:52 pm revealed Resident #83's urinary catheter tubing was not secured with a leg strap, and her urinary catheter drainage bag was noted to be undated. An observation on 09/29/22 at 9:22 am revealed the catheter still did not have a securing device in place, and the catheter was stretched tight over Resident #83's upper thigh. Resident #83 was exhibiting discomfort in that she was restless in bed (bending her legs up and down the mattress) and unable to articulate what the problem was until CNA G adjusted the catheter to release the tension. Once the tension was relieved, the resident stopped moving her legs back and forth. An interview with CNA G on 09/29/22 at 9:22 am revealed the CNAs were responsible for making sure leg straps were in place. She said the straps were to prevent what just happened with Resident #83-moving her legs around. She said she was not sure why Resident # 83 did not have one. She said she would replace it but there were none in the supply room and she would have to find one in another supply closet. An interview with LVN H/charge nurse on 09/29/22 at 01:19 pm revealed the CNAs were responsible for making sure leg straps were in place. He said leg straps were important because they kept the catheters from moving back and forth which could promote infection. An interview with the DON on 09/29/22 at 4:30 pm revealed the catheter securing device was more of an option. She said the purpose of the leg strap was for residents when getting up and there was a chance for dislodgement of the catheter. She also said it did not make a difference (for infection control) if the unstabilized catheter was moving in and out of the meatus and had diarrhea on it that could cause a UTI. She said the charge nurse made the decision about whether a leg strap was to be placed or not. Interview with the Director of Nurses (DON) on 09/29/22 at 4:34 PM revealed she said Leg straps are used as needed like when there is a risk of the catheter being dislodged or pulling. I don't know if a leg strap makes that much of a difference if they have diarrhea. The DON said the residents nurse would make the decision whether their resident needed it. The DON said if the resident verbalized 676321 Page 8 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that the catheter tubing was pulling or was uncomfortable for her Then yes the leg strap would be used. The DON said multiple in-services were conducted about putting the catheter drainage bag in a grey basin. There is a potential for infection with the catheter drainage bag being on the floor. It is all of the nurses and nurse aides responsibility to ensure there is the basin under the catheter drainage bag. Record review of the facility's undated Catheter Care, Urinary policy and procedure documented The purpose of this procedure is to prevent infection of the resident's urinary tract 1. Review the resident's care plan to assess for any special needs of the resident . 11. Be sure the catheter tubing and drainage bag are kept off the floor The facility's Catheter Care policy and procedure did not address securing of the catheter tubing for prevention of pulling and/or injury. Record review of Lippincott Nursing Procedures eighth edition pages 386-388 documented Implementation: Catheter Care: Make sure the catheter is properly secured. Assess for securement device daily and change it when clinically indicated and as recommendedby the manufacturer .If a securement device isn't available use piece of adhesive tape to secure the catheter. NURSING ALERT: Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen (produces a spiral stream of urine and has the effect of cleaning the opening) and bladder wall Record review of the CDC (centers for disease control and prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, updated June 2019 indicated on Pg. 12 of 61 II. Proper Techniques for Urinary Catheter Insertion, under E. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. 676321 Page 9 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to store all drugs and biological's in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys for one nurse medication cart (200 Hall) out of three medication carts reviewed for labeling and storage of biologicals, in that: 1a. LVN E left the 200 Hall medication cart unlocked and unattended. b. LVN E left Resident #85's insulin vial on top of the medication cart unlocked and unattended. 2. The facility failed to store controlled medications awaiting to be destroyed in a permanently affixed compartment for storage. These deficient practices could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel. The findings included: 1a &b. Observation of 09/28/22 at 7:45 AM of the 200 Hall medication nurse cart revealed the cart was unlocked and not attended to by any staff. At 7:47 AM, LVN E opened the door, walked out of Resident #85's room, which was located across from the medication cart, and immediately said I left it unlocked, I walked in the room and forgot to lock it. LVN E said the medication cart should be locked when not in use. LVN E said leaving the medication cart unlocked could lead to a resident or anyone else getting in the cart and taking medications that were not prescribed to them. Observation of medication pass on 08/28/22 at 07:47 AM revealed LVN E administered Resident #85 her medications. LVN E walked out of Resident #85's room holding Resident #85's Lantus (A drug used to control the amount of sugar in the blood of patients with diabetes) vial then set the vial on top of the medication cart. Approximately 30 seconds later, LVN E walked back into Resident #85's room and bathroom to wash her hands leaving the Lantus insulin vial on top of the medication cart, unsecured and out of her line of sight. Interview with LVN E on 09/28/22 at 7:58 AM revealed she said she forgot she left Resident #85's Lantus vial on top of the medication cart unsupervised. LVN E said she should have put the vial back in her medication cart and lock it. LVN E said she knew she should not leave medication unlocked and unsupervised but I wasn't thinking. LVN E said she did not recall when she last received any training on proper medication storage but had been a nurse working in a hospital and knew about keeping medications locked. LVN E said leaving the medication out unlocked and unsupervised could allow easy access to the medication by anyone and possibly cause an adverse reaction. Interview with the Director of Nurses (DON) and the Administrator on 09/30/22 at 8:53 AM revealed the DON said medication carts should be locked at all times, when not in use. The DON said medications should not be left on top of the medication cart unsupervised. The DON said medications should not be left unsupervised because anyone could get the medication and take it and possibly ingest it and have a reaction. The DON and Administrator said they both conducted rounds throughout the facility multiple times a day checking medication carts. 676321 Page 10 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of LVN E's Orientation Skills Checklist dated 07/21/22 revealed she demonstrated competency in the areas of pharmacy services and medication administration. 2. Inspection of the facility's designated controlled medication storage located in the Director of Nurses (DON) office locked closet revealed 17 controlled medications were stored in the two drawer file cabinet. The file cabinet was not permanently affixed to the wall or floor. The DON demonstrated repositioning of the cabinet when removing the medications from the top drawer. The following medication blister packs and/or liquids were located in the top drawer: Tramadol (pain medication used to treat mild to moderate pain) 50 milligrams (mg) blister pack - 88 tablets Hydrocodone (narcotic analgesic agent for the treatment of moderate to moderately severe pain) 10mg-325 mg blister pack - 12 tablets Clonazepam (used to prevent and control seizures) 0.25 mg blister pack - 45 tablets Acetaminophen with Codeine (used to relieve mild to moderate pain) 100 mg/ 5 ml solution - 300 ml solution Hydrocodone 5 mg-325 mg blister pack - 34 tablets Morphine Sulfate (opioid drug used to treat moderate to severe pain) 100 mg/5 ml solution - 29.25 ml solution Lorazepam Intensol (used to treat anxiety) 2 mg/ml solution - 20.75 ml solution Alprazolam (used to treat anxiety and panic disorders) 0.5 mg tablets - 91 tablets Interview with the DON on 09/30/22 at 10:53 AM revealed she said she did not know the cabinet should be permanently affixed. The DON said she had not have a permanently affixed storage area for the controlled medications. The DON said the controlled medications should be in a permanently affixed area to prevent from someone taking the entire cabinet with the medications in it. Interview with the DON on 09/30/22 at 2:01 PM revealed she said she searched the facility's policy and procedures and did not have a policy regarding storage of controlled medications needing to be stored in a permanently affixed compartment storage. Record review of the facility's Controlled Substance Destruction policy and procedure dated 10/01/19 documented Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Record review of the facility's Medication Carts and Supplies for Administering Meds policy and procedure dated 10/01/19 documented .The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Med Carts: 676321 Page 11 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0761 .2. The medication cart is locked at all times when not in use. Level of Harm - Minimal harm or potential for actual harm 3. Do not leave the medication cart unlocked or unattended in the resident care areas. Residents Affected - Some 4. Wheel the medication cart to the resident's room when passing medications or park the medication cart in the doorway of the room with drawers facing the nurse as she/he stands in the room. The cart must maintain in your line of sight when it is not locked. Medication Administration Guidelines: .f. Don't leave bottles or cards. etc. out on top of the med cart or counter. Keep wandering or mentally impaired patients in mind. g. Wash you hands with soap and water or sanitize your hands before giving someone medication. h. Wash your hands after you give someone medication. P. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by . 676321 Page 12 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for five Residents (#10, #9, #2, #34, #14) of 15 residents reviewed for infection control practices, in that: Residents Affected - Some 1. CMA B failed to perform hand hygiene after touching various contaminated objects, prior to putting on clean gloves, and prior to administering Resident #10 her eye drops. After administering Resident #10 her eye drops, CMA C scrubbed her hands with soap and water for only 8 seconds. 2. CMA B failed to perform hand hygiene after touching various contaminated objects, prior to grabbing clean gloves and putting them on, and prior to administering Resident #9 his eye drops. After administering Resident #9 his eye drops, CMA C scrubbed her hands with soap and water for only 10 seconds. 3. LVN A failed to wash her hands for at least 20 seconds, stored clean gloves in her pockets contaminating them and using them to administer Resident #2's medication via his feeding tube. 4. CMA C failed to sanitize the shared electronic wrist blood pressure cuff between use on Resident #23 and Resident #34. 5. CNA F failed to perform hand hygiene prior to incontinent care and proceeded to don new gloves. Between glove change, CNA F failed to perform hand hygiene and donned new gloves. CNA F opened Resident #14 new brief and placed inside of new brief over Resident #14 footboard with inside of brief making contact with footboard. 6. CNA G failed to sanitize her hands in between glove changes x4 during incontinent care, touched Resident #34's pillows and clean bed covers with soiled gloves on. These failures could place residents that require assistance with personal care and medication administration at risk for healthcare associated cross-contamination and infections. The findings included: Record review of the facility's Handwashing- Hand Hygiene policy and procedure dated January 2018 documented The facility considers hand hygiene the primary means to prevent the spread of infection .All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Wash hands with soap and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea . Use alcohol-based hand rub for the following situations: .b. Before and after direct contact with residents; 676321 Page 13 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 c. Before preparing and handling medications; . Level of Harm - Minimal harm or potential for actual harm i. After contact with a resident's intact skin: . l. After contact with objects in the immediate vicinity of the resident; Residents Affected - Some m. After removing gloves . Washing Hands: 1. Vigorously lather hands with soap and water and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature . Applying and Removing Gloves: .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. 1. Record review of Resident #10's face sheet dated 07/24/19 documented an [AGE] year-old female with the diagnoses of: unspecified dementia, anxiety disorder, osteoporosis (condition in which bones become weak and brittle), glaucoma (group of eye conditions that can cause blindness) and diabetes mellitus (high blood sugar). Record review of Resident #10 September 2022 physician orders documented Brimonidine Tartrate Solution 0.2 % (used to treat glaucoma- high pressure in the eye) Instill 1 drop in both eyes two times a day for glaucoma. Observation of medication administration on 09/27/22 at 2:42 PM revealed CMA B retrieved Resident #10's Brimonidine Tartrate 2% Ophthalmic Solution from her medication cart. CMA B was observed to touch her computer, computer mouse, medication cart, and medication cart lock with her right hand. While entering Resident #10's room, CMA B used her right hand to knock on the door then immediately grabbed two gloves from the box of gloves that were located on a wall rack inside of Resident #10's room. CMA B put on the gloves and administered Resident #10 her eyedrops without performing any hand hygiene. After administering Resident #10's medication, CMA B washed her hands, scrubbed her hands with soap and water for a total of 8 seconds, before rinsing her hands. 2. Record review of Resident #9's face sheet dated 09/29/22 documented a [AGE] year-old male admitted [DATE] with the diagnoses of: Dementia, glaucoma (group of eye conditions that damage the optic nerve often from high pressure in the eye), cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), and heart failure. Record review of Resident #9 September 2022 physician orders documented Brimonidine Tartrate Solution 0.2 %, Instill 1 drop in both eyes two times a day for glaucoma; Levetiracetam (used to treat seizures) 500 mg orally daily for seizures. Observation of medication administration on 09/27/22 at 2:51 PM revealed CMA B retrieved Resident 676321 Page 14 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #9's Brimonidine Tartrate 0.2% Ophthalmic Solution and Levetiracetam 500 mg tablet from her medication cart. CMA B was observed to touch her computer, mouse, medication cart, various medication blister packs, and medication cart lock with her right hand. While entering Resident #9's room, CMA B used her right hand to knock on the door then immediately grabbed two gloves from the box of gloves that were located on a wall rack inside of Resident #9's room. CMA B put on the gloves and administered Resident #9 his tablet then the eyedrops, with the same gloves and without performing any hand hygiene. After administering Resident #9's medication, CMA B washed her hands, scrubbed her hands with soap and water for a total of 10 seconds, before rinsing her hands. Interview with CNA B on 09/27/22 at 2:56 PM revealed she said her medication cart, computer mouse, and medication blister packs and bottles in her cart were not considered clean. When asked what she should have done prior to putting on gloves and administering eye drops, CMA B said I should have washed my hands to prevent cross contamination. CMA B said hand washing should be performed for 5-8 seconds then said Ughhh, wait, I don't remember, I'm getting nervous. I get trained like every month and right now I can't remember how long I'm suppose to wash my hands. CMA B said she should have not put on her gloves when giving Resident #9 his Levetiracetam pill because then the gloves were considered contaminated when she administered the eye drops. CMA B said it was important to perform hand hygiene/hand washing to prevent transferring of germs and infection. CNA B said she was last trained on hand hygiene approximately one month ago and said she received continuous training on hand hygiene at least every month or sooner. 3. Record review of Resident #2's face sheet dated 09/29/22 documented a [AGE] year-old male admitted [DATE] with the diagnoses of: dementia, gastrostomy (tube inserted into the stomach used for hydration, feeding, and medication administration), and glaucoma. Observation of medication pass on 09/28/22 at 07:29 AM revealed LVN A retrieved gloves from her medication cart and stored them on each side of her shirt pocket. At 7:30 AM, LVN A entered Resident #2's room and washed her hands, scrubbed her hands with soap and water for a total of 10 seconds before rinsing her hands with water. At 7:32 AM, LVN A retrieved a pink glove from her left shirt pocket and put it on her left hand then retrieved a blue glove from her right shirt pocket and put it on her right hand. LVN A then administered Resident #2's medications via his feeding tube. After medication administration, LVN A removed her gloves and disposed of them into the trash can and walked out of the room holding a small tray. At 7:37 AM, LVN A placed the tray on her medication cart then used her left index finger to touch her computer screen. LVN A then struck her right hand in her right shirt pocket and retrieved a small hand sanitizer bottle then sanitized her hands, putting the hand sanitizer bottle back in her right shirt pocket. Interview with LVN A on 09/28/22 at 07:42 AM revealed she said she considered her shirt pockets partially clean. LVN A said her hand sanitizer bottle would be considered dirty because she touched it when her hands were dirty. LVN A said I put the gloves in my pocket because I was carrying the medications and did not have a spare hand to carry the gloves in the room. I guess putting them in my pocket would then contaminate them. LVN A said using contaminated gloves while conducting medication pass could place the resident at risk for cross-contamination and infection. LVN A said she was taught to wash her hands with soap and water for 20 seconds, before and after resident care. LVN A said she usually sang the ABC or Happy Birthday song once to herself while washing her hands to meet the 20 second time limit. LVN A said she I thought I sang it, I'm not sure. LVN A said she did not wash her hands after removing her gloves because she was holding the unsanitized tray and did not realize she touched her computer screen before sanitizing her hands. LVN A said touching the computer screen contaminated the screen and her hands. LVN A said she should have washed her hands after removing 676321 Page 15 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her gloves, prior to exiting the room and washed her hands with soap and water for 20 seconds to prevent risk of resident infection. LVN A said she was last trained on hand hygiene approximately one month ago. 4. Observation of medication pass on 09/28/22 at 8:04 AM revealed CMA C checked Resident #23's blood pressure using a wrist electronic blood pressure cuff/monitor. CMA C walked out of the room and placed the wrist blood pressure cuff on her medication cart. At 8:11 AM, CMA C grabbed the wrist blood pressure cuff from the top of her cart and used it on Resident #34 to check her blood pressure, without sanitizing the cuff/monitor. Interview with CMA C on 09/28/22 at 8:21 AM revealed she said she usually used her hand sanitizer to sanitize the blood pressure cuff/monitor. CMA C demonstrated rubbing hand sanitizer on her hands and then rubbing it sparingly on some areas of the blood pressure cuff. When asked if she did so between using the cuff/monitor between Residents #23 and #34, she said No, I forgot, I didn't even think about it. When asked if she felt that hand sanitizer was sufficient enough to disinfect equipment, CMA C said I think so. We also have wipes. CMA C pulled out Micro Kill Sani-wipes and said We can use these too. CMA C said it was important to sanitize equipment between resident use to kill bacteria and prevent transmission of viruses and disease. Interview with the Director of Nursing (DON) and Administrator on 09/30/22 at 8:49 AM revealed the DON said staff should be performing hand hygiene before and after resident contact, when in contact with various objects, and between glove changes. The DON said staff should be washing their hands, scrubbing for 20 seconds. The DON said storing gloves in their pockets was appropriate and that she would store gloves in her pocket. The DON said the gloves are not sterile so that is okay. When asked if staff pockets were considered clean, the DON said Yes. When asked what if staff were storing hand sanitizers, keys, and pens in their pocket and constantly putting their hands in their pockets to put in or remove the hand sanitizer, then would the pockets still be considered clean, the DON said Yes. When asked if she agreed with the DON, the Administrator said Yes, I do. The DON explained If I am doing a procedure, I am not going to walk away from the resident to get gloves when I can get them out of my pocket and stay with the resident. The DON said she would not expect staff to disinfect electronic blood pressure cuffs between resident use because Those are partly cloth and well if I knew the resident had something transmittable then I would say yes, disinfect it, but honestly, I would not disinfect it after each use. If disinfecting, we have disinfecting wipes for that purpose that the staff carry in the med carts. When asked if she agreed with the practice, the Administrator said she agreed. The DON said the negative outcome for the resident would be placing the resident at risk for exposure to infection. The DON said she was responsible for ensuring all staff were trained on hand hygiene/infection control practices and either she or her ADON conducted trainings and staff return demonstration hand hygiene audits weekly for compliance. 5. Record review of Resident 14's face sheet dated 9/29/22 documented a [AGE] year-old female admitted on [DATE] with a diagnosis of Type 2 diabetes(condition resulting from insufficient production of insulin, causing high blood sugar), Expressive language disorder (learning disability affecting communication of thoughts using spoken language), Hypertension (high pressure in the arteries, vessels that carry blood from the heart to the rest of the body), Cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain), Hemiplegia and hemiparesis (weakness on half of the body), Muscle wasting and atrophy, Major depressive disorder , Dementia (a group of symptoms that affects memory, thinking and interferes with daily life), Hyperlipidemia (abnormally high concentration of fats or lipids in the blood), Nontraumatic subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissue covering the brain). 676321 Page 16 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Level of Harm - Minimal harm or potential for actual harm Observation on 09/29/22 at 09:29 AM of CNA F performing incontinent care on Resident #14. CNA F did not perform hand hygiene prior to incontinent care and proceeded to put on gloves. CNA F then proceeded to perform peri care on Resident #14 and between glove change, CNA F failed to perform hand hygiene and put on new gloves. CNA F opened Resident #14 new brief and placed inside of new brief over Resident #14 footboard with inside of brief making contact with footboard. Residents Affected - Some Interview with CNA F on 09/29/22 at 11:23 AM revealed she takes responsibility for not performing hand hygiene prior to performing incontinent care and between glove changes. CNA F stated placing the open brief over Resident #14 footboard is a breach in infection control. This surveyor asked what adverse effects could take place by placing open brief over footboard and not performing hand hygiene. CNA F stated, Resident can get an infection and UTI. CNA F stated she was nervous and does not normally provide care this way. 6. Record review of Resident #34's Face sheet dated 04/08/22 documented a [AGE] year-old female with an admission date of 04/08/2022 with diagnoses of Dementia, obstructive and reflux uropathy (from the prolapsed uterus), heart failure, high blood pressure, acid reflux, constipation, lung disease, muscle wasting, lack of coordination, anxiety, insomnia, depression, mood disorder, and stroke. Observation on 09/29/22 at 9:22 AM of CNA G at bedside for incontinent care. Washed hands, gathered supplies: trash bags, wipes, barrier cream, brief, gloves. Resident # 34 was able to assist turning. CNA G donned (put on) gloves, removed the brief (heavily soiled with thin unformed stool) and placed in trash bag. Gloves were doffed (taken off). No hand hygiene was performed. Gloves were donned. Peri area swiped with multiple wipes and each discarded into the trash bag. Gloves were doffed. No hand hygiene was performed. Gloves were donned. CNA G moved to other side of bed, Resident # 34 turned self to accommodate incontinent care. Swipes made with multiple wipes and discarded into the trash bag. Gloves were doffed. No hand hygiene was performed. Gloves were donned, clean brief applied. Pillows were touched with the same gloves. The soiled fitted sheet was removed and placed in a different trash bag. Gloves were not changed. The top sheet and blanket were placed over Resident # 34. Gloves were doffed. No hand hygiene was performed. The catheter did not have a securing device in place. Interview with CNA G on 09/29/22 at 9:32 AM said the CNAs were responsible for making sure leg straps were in place. She said she was not sure why Resident # 34 did not have one. She said she would replace it but there were none in the supply room. Interview with LVN H on 09/29/22 at 01:19 PM revealed Resident # 34 was notorious for removing her leg strap. He said the CNAs were responsible for making sure leg straps were in place. He said leg straps were important because they keep the catheters from moving back and forth which could promote infection. Interview with LVN V on 09/29/22 at 11:29 AM. LVN V was able to partially identify the proper steps of incontinence care. This surveyor asked if having an open brief over a resident's footboard was proper infection control standards for this facility. LVN V stated it was not. LVN V stated she has not performed incontinence care in a while and could not recall and verbalize the proper procedure for incontinence care at this time. Interview with housekeeping on 09/29/22 at 1:20 PM revealed housekeeping does disinfect high traffic areas daily starting at 8:00 AM. Housekeeper M and Housekeeper N stated they start disinfection in the common areas first, then facility restrooms, then resident hallways only after resident 676321 Page 17 of 18 676321 09/30/2022 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some breakfast trays are picked up and removed from rooms. Breakfast trays in Resident #14 hall were noted at time incontinence care was to be performed. Interview with DON and Administrator on 9/30/22 at 8:52 AM. The DON stated proper hand washing should be done for at least 20 seconds. Should be done before donning gloves, in between glove changes and after doffing gloves. Negative outcome for residents could be potential risk of transferring germs from one resident to another, cross contamination. Latest training on Infection Control conducted on 9/21/22. The DON stated all staff received training. The DON conducts hand washing audits. Audits of hand washing is when facility administration watches staff wash hands and conducts checkoff sheets. This surveyor asked the DON, while performing incontinent care when should hands be washed. DON stated before and after incontinent care. This surveyor asked if hand hygiene should be performed during glove change while performing incontinent care and DON stated, not necessarily, it is a dirty procedure, so no. This surveyor asked the DON and Administrator if placing the inside of a residents clean brief over a residents footboard is acceptable practice. The Administrator stated, these briefs are packaged and handled over and over without gloves many times before coming to the facility so yeah, it is ok, it is not a sterile procedure. The DON stated, it is ok, it is not like the brief was on the floor or anything like that. I know that housekeeping cleans the residents' rooms including the head and footboards. I informed the DON and Administrator that this surveyor interviewed housekeeping and during that time of incontinent care with this particular resident, housekeeping had not disinfected this resident's footboard that day. The DON stated, it is not like a lot of people are going in there and touching residents footboards. Record review of the facility's Medication Administration policy and procedure dated 10/01/19 documented Procedure: B. Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, and parental preparations. Hand sanitization is done with an approved sanitizer between handwashings, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface) . Record review of the facility's Medication Administration: Medication Carts and Supplies for Administering Meds policy and procedure dated 10/01/19 documented The facility maintains equipment and supplies necessary for the preparation and administrations of medication .Administration: I. Hands are washed before putting on examination gloves and upon removal for administration of topical, ophthalmic, injectable, enteral, rectal and vaginal medications. Record review of the facility's Cleansing and Disinfection of Resident - Care Items and Equipment dated January 2018 documented Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection . 676321 Page 18 of 18