Health inspection·March 13, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of expired medications for 1 of 4 medication carts (Hall #3 med-cart, a mobile cart used to pass medication) reviewed for storage and 1 of 1 medication room (med-room [ROOM NUMBER]) reviewed for storage, as well as the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 4 med-carts (Hall #3 med-cart) reviewed for storage. 1). The facility failed to dispose from hall #3 med-cart a bottle of antacids that had expired in March of 2022 and a saline enema that had expired in January of 2025. 2.) The facility failed to dispose from med-room [ROOM NUMBER] a box of single dose, prefilled Pneumonia vaccine syringes. 3.) The facility failed to keep Hall #3 med-cart free from employee personal items on 03/12/25 as there was a personal cell phone and a personal aluminum water bottle in bottom drawer of Hall #3 med-cart. 4.) This deficient practice could place residents at risk of receiving medications that were both expired and possibly cross-contaminated by personal items. The findings included: During an observation on 03/12/25 at 12:50 PM of med-pass from Hall #3 med-cart revealed Hall #3 med-cart had an open generic bottle of antacids, approximately 75% full, that had expired in March of 2022, as well as an unopened saline enema that had expired January of 2025, and a personal cell phone and personal aluminum water bottle in the bottom drawer with the blood pressure cuff, plastic cups and disinfecting wipes. During an observation on 03/12/24 at 1:15 PM of the medication refrigerator in med-room [ROOM NUMBER] revealed an open box of 5 single dose, prefilled, Pneumonia vaccine syringes that had expired on 02/05/25. In an interview with MA-D on 03/12/25 01:18 PM, she stated that personal items were not supposed to be in a med-cart because it can cause cross contamination with the medication, but that the items in the cart were not hers, and she did not know who they belonged to. She also stated that she usually checked her med-cart for expired medications, and she had not realized that there were expired Page 1 of 6 676321 676321 03/13/2025 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 - Few medications in the cart. She stated that if expired medications were administered to the residents, they might be ineffective or could possibly make them sick. In an interview with the DON on 03/12/25 01:10 PM, she stated that the nurses knew they were not supposed to have personal items in the med-cart, and that water bottle did belong to MA-D because she had overheard her earlier in the day saying that she used it to give residents tap water. She stated she was not sure about the phone, but assumed it was MA-D ' s since it was with her water bottle, and she did not understand why she lied about it when she should have just told the truth. The DON also stated it was everyone's responsibility to check for expired meds, and ADONs checked carts weekly, and if an expired medication was left on the cart or the in the med-room nurses could possibly give a medication that was less effective or not effective at all. In an interview with ADON-A on 03/12/25 at 5:21 PM, she stated that it was all the nurses and medication aides ' responsibilities to check their med-carts for expired meds, as well as the ADONs checked them weekly, so she was unsure of how the expired medications got missed on Hall #3 ' s med-cart, and giving expired medications to residents could make them sick. She also stated that the nurses were not supposed to keep personal belongings in the med-carts due to possible cross-contamination with the medications. In an interview with DON 03/13/25 12:25 PM, she stated that she looked for a policy on med storage, personal items in the med cart and expired meds, but she could not find any policies specific to these things. Record review of Medication Policies revised 10/01/19 revealed drugs, which have been dispensed for individual residents, were not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy. It was the responsibility of all nurses who administer medications to monitor the expiration dates of the medication. Expired medications would not be administered in the facility. All expired medications would be disposed of per facility policy. Record review of Medication Administration: Medication Carts and Supplies for Administering Meds policy revised 10/01/19 revealed the facility maintains equipment and supplies necessary for the preparation and administration of medication to residents. The purpose of the mobile medication system was to ensure appropriate control and surveillance of resident assigned medications. 676321 Page 2 of 6 676321 03/13/2025 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, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 5 of 25 residents observed for infection control practices, in that: Residents Affected - Few 1. The facility failed to ensure LVN H and the RA appropriately followed infection control practices when the RA grabbed the top of resident cups by top rims with bare hands, and LVN H grabbed sliced bread, while passing out meal trays to 5 of 25 residents in the dining room during lunch on 03/11/25. 2. The facility failed to post Enhanced Barrier Precaution signs outside the rooms of Resident #88 and #105, so staff and visitors were unaware of what if any precautions were need prior to entering the room. These failures could place residents at risk for cross contamination and infection. Findings include: 1.) During an observation of lunch on 03/11/25 at 12:46 PM LVN H was observed using bare hands to grab the bread slices out of the plastic wrap and placed it on resident trays. An RA was seen grabbing resident cups by the top rim with bare hands and placing it on resident trays. In an interview on 03/11/25 at 12:50 PM LVN H stated she had training once on passing out meal trays since she's been working at facility. LVN H stated staff are not allowed to grab the resident ' s bread or any food with bare hands and did not realize she was doing so. LVN H stated by grabbing resident ' s bread with bare hands, it could spread infections to residents. LVN H stated the last infection control in-service was about a month ago. In an interview on 03/11/25 at 12:59 PM the RA stated he was trained about a few months ago on food handling and passing out meal trays. The RA stated he thought he was grabbing the cups on the sides. The RA stated, well did you see my sanitize my hands? The RA stated the top rim of the cups should not be touched with bare hands as it could spread infection to the residents. The RA sated the last infection control service was about a month and a half ago. In an interview on 03/13/25 at 09:14 AM the DON stated staff should not be grabbing the resident cups by the top rim or grabbing food items such as bread with their bare hands due to infection control. The DON stated by grabbing food items and touching the top rims of resident cups could spread germs to residents. The DON stated an In-service for all staff on food handling and tray set up was conducted on 3/11/25 (observed through record review). In an interview on 03/13/25 at 09:31 AM ADON A stated staff should not be touching the top rims of the resident cups and food items with bare hands because it could contaminate the residents food with bacteria that could potentially be on their hands and spread those germs to the residents who will be putting the items in their mouths. ADON A stated an in-service with all staff was conducted on food handling and tray set up beginning on 3/11/25. 676321 Page 3 of 6 676321 03/13/2025 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Record review of the facility's Infection Prevention and Control Program dated 05/13/23 reflected: Level of Harm - Minimal harm or potential for actual harm Policy Residents Affected - Few This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2.) Record review of Resident #88's face sheet dated 03/13/25 revealed a [AGE] year-old-female with an original admission date of 09/25/24 and a current admission date of 01/22/2025. Record review of Resident #88 ' s admission MDS dated [DATE] revealed a BIMS of 15, intact cognition. The MDS also revealed urinary continence not rated as resident had a catheter. Record review of Resident #88 ' s care plan initiated 03/11/25 revealed a care plan for EBP due to foley catheter. Record review of Resident #88 ' s physician orders with a start date of 03/11/25 revealed an order for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices). The physician ' s orders also revealed an order with a start date 01/28/25 Foley catheter change 16 French (size of the barrel of the catheter) with 30 milliliter bulb as needed. During an observation on 03/11/25 at 10:14 AM of Resident #88 ' s door and room, there were no EBP signs posted, and there was not EBP - PPE cart posted. Resident #88 was also observed at this time to be wheeling out of her room with her Foley bag connected under her wheelchair in a privacy bag. Record review of Resident #105 ' s face sheet dated 03/13/25 revealed an [AGE] year-old-female with an original admission date of 02/25/25. Record review of Resident #105 ' s admission MDS dated [DATE] revealed a BIMS of 14, intact cognition. The MDS also revealed cardiopulmonary surgery involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords, as well as tracheostomy care. Record review of Resident #105 ' s care plan initiated 02/26/25 revealed a care plan for EPB due to trach. Record review of Resident #105 ' s physician orders with a start date of 03/02/25 revealed an order to change trach collar and tubing with oxygen condensation trap. It also revealed an order with a start date of 02/26/25 for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased 676321 Page 4 of 6 676321 03/13/2025 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 risk for MDR (residents with wounds or indwelling medical devices). Level of Harm - Minimal harm or potential for actual harm During an observation on 03/11/25 at 9:37 AM revealed no EBP sign or EBP - PPE cart on Resident #105 ' s door or wall. Residents Affected - Few In an interview with the wound care nurse on 03/12/25 at 9:25 AM, she stated precaution signs were there to keep the residents and staff safe, and if they were missing it puts all the residents at risk for cross-contamination and infection. She stated that typically the infection control nurse, one of the ADONs, or the DON put up the EBP signs and PPE carts. In an interview with CNA-F on 03/12/25 at 9:54 AM, he stated the ADONs typically put up the signs for EBP. CNA-F stated EBP included the use of gown and gloves with high contact due to them having a possible infection. He stated the precautions were there to keep from spreading infections, and if they did not have the proper signs, infections could spread. He stated that gloves and gowns were typically kept inside the room, but no carts outside that he has seen on the EBP rooms. CNA-F also stated it would be easier if the signs and PPE were outside the room so he would have known what precaution to take and what PPE to put on before entering the room. In an interview with the ICP / ADON-A on 03/13/25 09:20 AM, she stated the DON, ADONs and staff nurses were responsible for putting up EBP signage and carts. She stated that one of the rooms signs must have fallen, and the other room just got missed. If the proper signage and carts were not there, cross contamination could occur, and infections could spread. She also stated that there were no EBP - PPE carts on the doors our outside the rooms because corporate wanted supplies kept in the supply closets, so they kept EBP supplies in the closets, and staff get them from there prior to going into the room and delivering care. In an interview with the DON on 03/13/25 at 9:20 AM, she stated the DON or ADON was responsible for putting up EBP signage, and there was no reason that they were not put up, and they should have been there. The DON also stated the residents would not be protected if staff were not using the proper PPE, especially if they had not known the residents were on EBP. She stated a corporate decision was made to leave the PPE in the supply closets, but CDC recommendation and best practice was to have it available near the room with EBP. Record review of CDC: Long-Term Care Facilities: Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 04/02/24, revealed the use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves); For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that required the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room. Website reviewed on 03/13/25 at 10:00 AM: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/contain Record review of Enhanced Barrier Precautions policy dated 04/05/24 revealed 2) Initiation of Enhanced Barrier Precautions: b. an order for enhanced barrier precautions would be obtained for residents with any of the following: wounds, indwelling medical devices, infection, and/or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. 3) Implementation of Enhanced 676321 Page 5 of 6 676321 03/13/2025 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0880 Barrier Precautions: a. make gowns and gloves available immediately near or outside of the resident ' s room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676321 Page 6 of 6