Health inspection·May 10, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to other officials including adult protective services and law enforcement, for 3 of 5 residents reviewed for abuse (Residents #1, #2, and #4) The facility failed to report: -Resident #1's breast was grabbed on 01/23/23 occasion and slapped on the buttocks on 02/09/23 by (Resident #3) -Resident #2's breast was grabbed on 02/20/23 by Resident #3 -Resident #4 was slapped on the head on 01/29/23 by Resident #5 - The facility failed to implement the facility's policies and procedures for reporting to the proper authorities for Residents #1, #2, and #4 This failure could place residents at risk for unreported allegations of abuse without proper investigation and reporting Findings were: A record review of Resident #1's face sheet with an initial admission date of 04/13/21, and most recent admission of 06/21/21 documented an independent and self-representative [AGE] year-old female with relevant diagnoses of vascular dementia, without behavioral disturbance, chronic obstructive pulmonary disease, insomnia, heart disease, high blood pressure, anxiety disorder, major depressive disorder, muscle wasting and atrophy. A record review of Resident #1's MDS dated [DATE] documented she was a smoker had a BIMS score of 14, indicating intact cognition, was cognitively and functionally independent with a walker, was frequently incontinent of bowel and occasionally incontinent of the bladder and was receiving Psyche services. A record review of Resident #3's face sheet dated 07/31/21 and discharged [DATE] documented a [AGE] year-old male with diagnoses of vascular dementia, without behavioral disturbance, insomnia, heart disease, heart failure, chest pain, high blood pressure, reflux, muscle wasting and atrophy. Page 1 of 6 676321 676321 05/10/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0609 Resident #3. Was his own representative. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #3's MDS dated [DATE] documented he was a smoker and had a BIMS score of 12, indicating moderately impaired cognition, and a cognitive and functional ability to transfer himself with 1 staff to assist and was continent. MDS dated [DATE] documented a BIMS score of 12 and Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 1-3 days, and remained continent. Residents Affected - Some A record review of Resident #3's Change in Condition Report dated 02/09/23 documented: the resident stated he hit Resident #1 on her bottom to tell her to keep moving in the hallway, whereas he was separated from the other resident and placed on q15-minute monitoring. There were no other changes documented. A record review of Resident #3's Discharge Plan and Summary dated 02/22/23 documented the Reason for Discharge was inappropriate behaviors and discharge to a sister facility all-male unit. A record review of Resident #3's Care Plan dated 01/30/23 documented Resident #3 had the potential for inappropriate touching behavior. Date Initiated: 01/30/2023. Resident #3 will have no evidence of behavior problems by the review date. Date Initiated: 01/30/202. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed. Date Initiated: 01/30/2023.: Resident #3 was to be monitored by staff when interacting with Resident #1, whom he had previously touched. Date Initiated: 01/30/2023. Resident #3 was receiving Psychiatric services and was taking sedatives/hypnotics, and antidepressants. He was also being treated for his heart condition, high cholesterol, and high blood pressure. A record review of Resident #1's progress notes dated 01/23/23 at 3:50 pm documented Resident #1 was returning to the facility from a scheduled smoke break with Resident #3. When entering the building Resident #3 grabbed Resident #1's breast from behind. Resident #1 then came to the nurse's station and stated, I don't want him to be grabbing my breast. and pointed toward Resident #3. The nurse followed Resident #1 into her room to verify what had happened. Resident #1 stated, I don't want to get him in trouble I just want him to stop doing that. When Resident #1 was asked if it had happened before, Resident #1 stated, No he usually asks me to grab my breast, but I tell him no, but today he did it when I wasn't looking. A record review of the facility investigation report, completed by the ADM, dated 01/23/23 documented a resident-to-resident incident involving Resident #1 and Resident #3 upon returning from a smoke break wherein Resident #1 reported to a charge nurse that Resident #3 had grabbed her breast. She stated that she did not want to get him into trouble, she just wanted him to stop doing that. When asked if she would rather Resident #3 not attend smoking with her, she said, Oh, no, he is fine to continue to smoke with me as long as he doesn't do that again. She stated that they don't really talk much, and he doesn't bother her. She is not afraid of him. The SW and nurse visited Resident #3 and asked the resident if he had touched the other resident inappropriately. He stated yes, I don't know why, it just felt good to do. When told Resident #3 did not want him to do that again, he said okay, fine, I won't do it again. He said he was sorry and understood he was not to touch any resident in an inappropriate manner. Conclusion: Substantiated. This was a resident-to-resident incident. No further incidents between residents. Staff notified to monitor residents during smoke breaks and activities. 676321 Page 2 of 6 676321 05/10/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with the ADM on 05/09/23 at 2:15 PM stated he was surprised to find out that Resident #3 had been asking Resident #1 if he could touch her breasts, and after all the plans the facility put into place because of it, Resident #3 spanked Resident #1 on her butt. The ADM stated Resident #3 was discharged to another facility after moving to another hall, away from the female resident, which did not work out. An interview with the ADM on 05/09/23 at 3:50 PM stated he had not notified the local authorities about this sexual abuse. A record review of the facility investigation report, completed by the ADM, dated 02/09/23 documented a resident-to-resident incident involving Resident #1 and Resident #3; While returning from smoking, Residents #1 and #3 turned onto the hallway where they both resided. Resident #1 suddenly stopped with her walker due to obstacles and other residents in wheelchairs blocking her way. Resident #3 was directly behind her when she stopped. Resident #3 reportedly slapped Resident#1 on her bottom and told her to keep moving. Resident #1 cried out Stop that, which alerted staff to the incident. Conclusion: Substantiated. This was a resident-to-resident incident. No further incidents between residents. Staff notified to monitor residents during smoke breaks and activities. Residents now reside in different units so that they no longer walk together in the hallway to and from smoking. They no longer sit at the same table for activities and meals. We do not believe Resident #3 meant anything sexual with his slap on Resident #1's bottom. An interview with Resident #1 on 05/09/23 at 2:45 PM stated Resident #3 asked her if he could kiss her and she did a couple of times in the beginning, but that one time, he grabbed my breast from behind and she didn't like it. Another time he swatted her on her butt, and she was not expecting that, either. Resident #1 stated the facility got rid of him for it, and she was sad about that because he was a good guy and they all miss him. Resident #1 stated, he was just a dirty old man-it was no big deal, he just got a little too comfortable. Resident #1 stated they could have worked something out (she and Resident #3). Resident #1 stated she did not appreciate it when Resident #3 smacked her on the rear. Resident #1 stated, No one had the right to do that except her husband, and he was dead. Resident #1 stated she didn't want Resident #3 to get moved-he was a good friend, and his getting moved was worse than him smacking her. A record review of Resident #2's face sheet dated 07/08/21 documented a [AGE] year-old female with relevant diagnoses of Alzheimer's, major depressive disorder, recurrent, high blood pressure, diabetes, abnormalities of gait and mobility, muscle wasting and atrophy, dysphasia, and had total blindness in both eyes. A record review of Resident #2's MDS dated [DATE] documented a BIMS score of zero, indicating severely impaired cognition, as it was upon admission on [DATE]. A record review of the facility investigation report, completed by the ADM, dated 02/20/23 documented Resident #6 reported he had witnessed Resident #3 grab Resident #2's breasts. The report documented Resident #6 stated that Resident #3 had gone up to Resident #2 in the hallway and grabbed her breasts and she elbowed him, and he went back to his room. A full body assessment of Resident #2 showed no bruising. Residents #2 and #3 denied the incident but Resident #6 that reported the incident was alert and oriented and had a BIMS of 11, indicating moderate cognitive impairment. Resident #6 was unavailable for an interview during this investigation. 676321 Page 3 of 6 676321 05/10/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with the ADM on 05/09/23 at 3:50 PM stated he had not notified the local authorities about this sexual abuse. Observation and attempted Interview with Resident #2 on 05/10/23 at 10:37 AM revealed she was seated at a table in activities with 2 other female residents, observing per AA. Resident #2 was awake and sitting upright with her eyes closed in a wheelchair (she is totally blind). Resident #2 swung her feet with her ankles crossed. Resident #2 did not speak and would occasionally utter a low-pitched sound. The AA stated the resident could answer some questions. When asked by this surveyor if she enjoyed her lunch, she slurred, Yes. When asked what she had to eat, she slurred, Yes. A record review of Resident #5's face sheet documented an initial admission of 01/11/22 and re-admission on [DATE] and documented a [AGE] year-old male with relevant diagnoses of stroke, chronic viral hepatitis, seizures, alcoholic cirrhosis of the liver, traumatic subarachnoid hemorrhage (bleeding in the brain from trauma) without loss of consciousness, dysphagia, reflux, wasting and atrophy, and high blood pressure. A record review of Resident #5's MDS dated [DATE] documented he was a smoker, at risk for wandering, and had a BIMS score of 6, indicating severe cognitive impairment. A record review of Resident #4's face sheet dated 03/04/13 documented a [AGE] year-old male with relevant diagnoses of obstructive hydrocephalus, (too much fluid on the brain), heart disease, high blood pressure, stroke- affecting the left side, cataracts, epilepsy, osteoarthritis, kidney cancer, and abnormalities of gait and mobility. A record review of Resident #4's MDS dated [DATE] documented a BIMS score of 11, indicating moderately impaired cognition. A record review of the facility investigation report, completed by the ADM, dated 01/29/23 documented a resident-to-resident incident involving Resident #4 and Resident #5 wherein Resident #4 reported that Resident #5 came up to him in the dining room and slapped him on the head. Observation of Resident #5 in activities on 05/10/23 at 10:33 AM revealed he was seated at a table by himself. An interview with Resident #4 on 05/10/23 at 10:14 AM recalled the incident on 01/29/23-Resident #5 stated he was in the dining room waiting for breakfast and talking to his friend at the table and Resident #5 came up to him and hit him on the head for no reason. Resident #4 stated he asked Resident #5, How come you hit me? I didn't do nothing to you. Resident #4 stated he did not know Resident #5 was behind him. Resident #4 stated Resident #5 told him he needed to hush. Resident #4 stated he was singing, and he sang every morning about Jesus and thanked him for a beautiful morning. Resident #4 stated after Resident #5 hit him, LVN A took him away somewhere (he did not know where), and he ate his breakfast. Resident #4 stated he could not go into the dining room anymore until Resident #5 leaves (the dining room). Resident #4 stated he did not have any pain or anything (after he was slapped). Resident #4 stated the staff tells Resident #5 to leave him alone because he sang well. Resident #4 stated Resident #5 had not hit him again since. A record review of the facility investigation report witness statement written by LVN A stated Resident #4 reported to her after Resident #5 slapped him on the head. LVN A interviewed Resident #5 as to why he struck Resident #4. Resident #5 stated, Because he's mean, and I don't like him and the 676321 Page 4 of 6 676321 05/10/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some noise he makes. LVN A described Resident #5's behavior when he left the dining room as, Resident #5 got upset, threw his chair, and told her to go to hell as he left the dining room. LVN A was not available for an interview during this survey. An interview with Resident #5 on 05/10/23 at 1:20 PM stated he did not recall the incident but stated he gets mad sometimes for no reason and that he had hit people before. Resident #5 stated his head was messed up. Resident #5 then stated he hit someone a long time ago but no one since then. When asked why he hit the other resident, he stated, I forgot. Resident #5 stated he gets upset easily sometimes but did not know why. Resident #5 had nothing else to say. An interview with the ADM on 05/10/23 at 1:45 PM stated there had been any other incidents with Resident #5. An interview with CNA A on 05/10/23 at 2:25 PM stated if she saw something, she would tell the ADM and put that person in safety or use the chain of command-tell the nurse. CNA A stated she had never had to report abuse in her 22 years of experience. An interview with CNA B on 05/10/23 at 2:28 PM stated she had never had to report abuse. CNA B stated abuse was any molestation or anything the residents might do, like hitting or biting-things like that. CNA B stated she would report any kind of abuse to the ADON or the charge nurse or the DON, and especially the ADM. CNA B stated she gets training on abuse & reporting-last time was last month. An interview with the ENV on 05/10/23 at 2:28 PM stated she had never had to report abuse for anybody like a resident or staff. The ENV stated she would tell the ADM because he was the Abuse coordinator. The ENV stated she gets training on abuse at least monthly or if something happened-last training was last month. An interview with the RCS on 05/10/23 at 2:40 PM stated the ADM was the Abuse Coordinator. The RCS stated the ADM had not called the local authorities and he should have. The RCS stated the ADM had not called the local authorities because it was not in the latest guideline he referred to. The RCS stated the ADM was advised to go by the facility policy. The RCS stated her director of clinical operations said the same thing. The RCS stated multiple in-services on abuse and reporting abuse have been done. The RCS stated she did not know if the ADM had attended one. An interview with the DON on 05/10/23 at 2:44 PM stated abuse should be reported immediately to the abuse coordinator (ADM) first, then her, whom she would report to the ADM. The DON stated reporting to the local authorities should be part of the reporting requirements. The DON stated she placed the plan (care plans) that staff had to be with the smokers, and a staff member was always with the smokers and individually if only one of the residents wanted to go to smoke. The DON stated she was responsible for care planning and in-services to the nursing staff. The DON stated the ADM did not ask her advice on whether he should or should not call the local authorities. An interview with the ADM on 05/10/23 at 3:00 PM stated he did not call the local authorities because he had not associated the sexual abuse and abuse with a crime. The ADM stated that had the sexual abuse and the abuse had been from an outside person, it would have triggered to call the local authorities. The ADM stated he was not advised by anyone to not call the authorities when he consulted with corporate. The ADM stated it was important to tell local authorities if there were a crime. The 676321 Page 5 of 6 676321 05/10/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ADM stated he didn't think the sexual abuse and abuse was a crime. The ADM stated he called HHSC, had a group meeting with corporate and it did not come up and he could not say why he did not report the sexual abuse and abuse to the local authorities. The ADM stated he could understand if the sexual abuse was an aggressive kind of situation, but it was not, and it just did not click. The ADM provided police reports for intakes 407620, 402567, and 405763. The reports were dated 05/09/23 at 4:29 PM. The ADM stated he had not read the facility policy on abuse. A record review of the facility policy, Abuse, Neglect, and Exploitation dated 08/15/22 documented that abuse means the willful infliction of injury . willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Law enforcement is the full range of potential responders to elder abuse, neglect, and exploitation including police, sheriffs, detectives, public safety officers . Under Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse . 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse . to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Under II. Employee Training, C. Topics will include 1. Prohibiting and preventing all forms of abuse .2. Identifying what constitutes abuse .3. Recognizing signs of abuse .4. Reporting process for abuse . Under VII. Reporting/Response, A. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . 676321 Page 6 of 6