Health inspection·October 20, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment for 1 of 1 hall reviewed for the environment in that: The facility failed to prohibit a gas-powered [NAME] from being driven inside the building. This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment Findings were: Observation on 10/19/23 at 3:15 p.m. revealed the MS unlocked, disarmed, and opened two doors at the end of hall 400 that led to the outside of the front of the facility, the other door was directly across the hallway leading outside to the courtyard. A person on a stand-up type lawn [NAME] drove the running [NAME] inside the building, through the doors, mowed the courtyard, and drove the running [NAME] back through the doors, into the building, across the hallway, and out of the facility. The MS closed, locked, and re-armed the doors after the [NAME] was outside the facility. An interview with the MS on 10/20/23 at 10:50 a.m. stated the maintenance department had been allowing the gas-powered [NAME] to come through the doorways forever. The MS stated, Yesterday, they came through the doors with the gas-powered lawn [NAME], across the hall, and into the courtyard to [NAME], then back through the doors, across the hallway. The MS stated the facility had a new lawn service, and they did not have access to open the doors. When asked who opened the locked doors for the [NAME] driver, the MS stated, That's a good question. The MS stated the maintenance department opened the doors. This surveyor stated, That would be you? The MS nodded his head up and down and stated, Yes, the maintenance department. The MS stated the lawn service used to weed-eat the courtyard and when asked what had changed, stated, That's a really good question, and could not say. The MS stated the maintenance department let them (the lawn service) in and opened the doors and it should not be allowed. The MS stated the maintenance department stood between the doors while the [NAME] crossed the hall to ensure no one got run over by the stand-up gas-powered [NAME]. When asked why gas-powered machinery should not be inside the facility, the MS stated, That's a really good question, then stated it was not good to allow a gas-powered [NAME] to go through the building because the combustion and exhaust could cause respiratory issues with the residents and staff, especially since the physical therapy department was only about 10 feet from the doors that were used to allow the gas-powered [NAME] to go through the building. The MS stated there was another way to get to the courtyard without driving a [NAME] through the building, but it was a long way around (on the sidewalk). Page 1 of 3 676321 676321 10/20/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the ADM on 10/20/23 at 4:33 p.m. stated since he had been at the facility, that was the first time he had heard of it (allowing a gas-powered [NAME] to go through the doors, cross the hallway, and return the same way). The ADM stated he spoke with the MS who told him it was a rare occurrence, and they usually only used a weed eater to [NAME] the courtyard. The ADM stated the MS told him the reason they did it (drive the [NAME] through the building) was because the grass was higher than usual. He told the MS to contact the lawn [NAME] company to tell them not to do that again, and the MS told the ADM he would call them ASAP. The ADM stated the MS had made that call and the lawn [NAME] company would speak with their staff. The ADM stated it could pose a situation where people (residents, staff, surveyors, visitors) could get hurt. The ADM stated, It was stupid for them to do that. It was lazy. The Adm stated that would never be okay (to drive a gas-powered [NAME] through the building). References: NFPA 99 Health Care Facilities Code (2012) 15.3 Special Hazard Protection for Flammable Liquids and Gases. 15.3.1 The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards: (1) NFPA 30, Flammable and Combustible Liquids Code NFPA 30 Flammable and Combustible Liquids Code (2012) 6.5 Control of Ignition Sources 6.5.1 General. Precautions shall be taken to prevent the ignition of flammable vapors by sources such as the following: (1) Open flames (2) Lightning (3) Hot surfaces (4) Radiant heat (5) Smoking (6) Cutting and [NAME] (7) Spontaneous ignition (8) *Frictional heat or sparks (9) Static electricity (10) Electrical sparks 676321 Page 2 of 3 676321 10/20/2023 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0584 (11) Stray currents Level of Harm - Minimal harm or potential for actual harm (12) Ovens, furnaces and heating equipment Residents Affected - Few 676321 Page 3 of 3