Health inspection·November 26, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of 5 residents reviewed for abuse. The facility failed to protect Resident #1 from Resident #2's sexual abuse on 11/21/25 in the dining room during dinner service at around 4:45 PM. This failure could lead to residents developing or exacerbating anxiety, depression, and feelings of embarrassment.The findings included:Record review of Resident #1's face sheet, dated 11/26/25, reflected a [AGE] year-old male with an original admission date of 01/11/22 and a current admission date of 05/03/25. Resident #1's pertinent diagnosis included Cerebral Infarction (a type of ischemic stroke where a blood clot blocks an artery in the brain, leading to the death of brain tissue). Record review of Resident #1's Quarterly MDS assessment, dated 10/17/25, reflected a BIMS score of 1 which indicated severe impairment. Record review of Resident #1's comprehensive care plan, dated 11/26/25, reflected the focus [Resident #1] is at risk for emotional distress r/t sexual incident involving another resident initiated on 11/21/25 and revised on 11/25/25. Interventions listed for this focus included Monitor [Resident #1] for any distress for 3 days initiated on 11/21/25, Psych services to follow up and Staff to ensure [Resident #1] and other resident maintain their distance both initiated on 11/25/25. Record review of Resident #2's face sheet, dated 11/26/25, reflected a [AGE] year-old female with an original admission date of 08/24/24 and a current admission date of 11/15/25. Resident #2's pertinent diagnosis included Alzheimer's Disease (progressive neurological disorder that is the most common cause of dementia, slowly destroying the ability to remember, think, and carry out daily tasks). Record review of Resident #2's Quarterly MDS assessment, dated 08/29/25, reflected a BIMS score of 6 which indicated severe impairment. Record review of Resident #2's comprehensive care plan, dated 11/26/25, reflected the focus [Resident #2] had an incident of inappropriate behavior involving another resident and sexual touching initiated on 11/21/25 and revised on 11/25/25. Interventions listed for the focus included closely monitor resident and ensure she is not sitting next to [Resident #1], Monitor for inappropriate behaviors q shift indefinitely, Monitor for triggers such as overstimulation, confusion, or loneliness and Place [Resident #2] on a 1:1 until 11/24/2025. In an interview with the SSD on 11/25/25 at 2:19 PM, the SSD stated at around 4:45 PM on 11/21/25 she was in the dining room speaking with residents. The SSD stated she made eye contact with Resident #1 from across the room and he gave her a strange look, like he was surprised. The SSD stated she saw Resident #2 sitting next to Resident #1. The SSD stated she bent down to see under the table and saw Resident #2's hand moving around on top of Resident #1's genital area over his pants. The SSD stated Resident #2 did not appear to be grabbing or rubbing with her hand motion. The SSD stated it did not look like Resident #2 was trying to give any sexual gratification to Resident #1. The SSD stated she immediately went over and moved Resident #2 to a different table in the dining room. The SSD stated it took about 10-15 seconds from when she first looked under the table to Page 1 of 3 676321 676321 11/26/2025 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when she had reached Resident #2 and moved her away from Resident #1. The SSD stated she told Resident #2 that what she was doing was inappropriate, but Resident #2 appeared confused and did not understand what she was doing. The SSD stated she informed the ADM about the incident once the two residents were separated. The SSD stated she had followed up with both residents since the incident and neither had any sign or symptoms of distress related to the incident. The SSD stated she was not aware of any past allegations of sexual abuse for either resident. The SSD stated it was important to protect residents from any type of abuse to ensure that they were not harmed. The SSD stated she was not sure if the physical contact was consensual. The SSD stated after reviewing everything she did not think this incident was sexual abuse. An interview was attempted with Resident #1 on 11/25/25 at 3:51 PM but he was not interviewable. In an interview with Resident #2 on 11/25/25 at 4:09 PM, Resident #2 stated she did not have any problems with any residents at the facility. Resident #2 stated she had never touched another resident inappropriately. Resident #2 stated she would never hurt another person at the facility. Resident #2 stated she mostly kept to herself. In an interview with SW on 11/26/25 at 9:06 AM, SW stated she worked for a local psychiatric services company contracted with the facility. SW stated she started working with Resident #1 and Resident #2 on 10/15/25. SW stated when she first met with Resident #1 he was reserved. Resident #1 stated he has opened up more to her over the past month. SW stated Resident #1 got defensive when she asked him about the sexual abuse incident. SW stated his demeanor changed when she asked him about the incident, indicating he might have remembered the incident. SW stated she asked Resident #1 if he wanted to talk about the incident but he told her no. SW stated Resident #1 told her he felt safe at the facility. SW stated, in her opinion, Resident #1 would be able to consent to sexual activity. SW stated she believed Resident #1 understood more than he communicated. SW stated when she spoke to Resident #2 she did not remember anything about the sexual abuse incident. In an interview with the DON on 11/26/25 at 9:21 AM, the DON stated she first found out about the incident when she received a call from the ADM at around 5:15 PM on 10/21/25. The DON stated she did not believe the contact between Resident #1 and Resident #2 was sexual. The DON stated she did not think Resident #2 intentionally touched Resident #1's groin area. The DON stated she thought if Resident #1 did not want Resident #2 to touch him he would have said something or left the table. The DON stated even though Resident #1 had a low BIMS score, he was still able to communicate when he was angry, sad, or happy. The DON stated she thought both residents were able to consent because they were both able to express their needs. The DON stated she did not think this incident was sexual abuse. The DON stated all residents had the right to be free from abuse at the facility. In an interview with the ADM on 11/26/25 at 10:00 AM, the ADM stated he first learned at the incident at around 5:00 PM on 11/26/25 when he received a call from the SSD. The ADM stated he was the abuse prevention coordinator at the facility. The ADM stated it was his responsibility to [NAME] the investigation, of abuse incidents, report them to the HHS, and keep residents safe. The ADM stated he felt that Resident #1 was able to consent to sexual contact. The ADM stated he did not think it was sexual contact between the two residents because there was no evidence Resident #2 was touching Resident #1 for the sexual gratification of anybody. The ADM stated he did not think this incident was sexual abuse. The ADM stated every resident had the right to be free from abuse at the facility. The ADM stated it was important to protect residents from abuse of any kind to keep them from harm. Record review of the facility's policy Abuse, Neglect and Exploitation, dated 07/11/25, reflected the following policies: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of 676321 Page 2 of 3 676321 11/26/2025 Windsor Nursing and Rehabilitation Center of Corpu 3030 Fig St Corpus Christi, TX 78404

F 0600 resident property. 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676321 Page 3 of 3