Health inspection·April 4, 2025

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 observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for 1 of 10 residents (Resident #1) reviewed for safe environment. The facility failed to ensure Resident #1's room temperature was maintained at or below 81 degrees. This failure could place residents at risk of living in an uncomfortable and unsafe environment and a diminished quality of life. Findings included: Record review of Resident #1's admission record, dated 04/04/25 reflected a [AGE] year-old female admitted to facility on 03/26/22. Her relevant diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath) and shortness of breath. Record review of Resident #1's quarterly MDS dated [DATE] revealed she had a BIMS score of 12, which indicated her cognition was moderately impaired. Record review of Resident #1's quarterly care plan dated 03/07/25 reflected she was on continuous oxygen therapy related to ineffective gas exchange. Interventions in part included to 2 liters per minute via nasal cannula. During an observation on 04/04/25 at 12:45 p.m., As soon as the door was opened the heat could be felt. Resident #1 was observed lying in bed awake and was on oxygen therapy via nasal canula. She had two portable fans directly across her bed that were on. In an interview on 04/04/25 at 12:46 p.m., Resident #1 said her room was too hot. She said the two fans helped but it was still hot and at times it was hard for her to breath. Resident #1 said she started feeling the change in temperature 2 days ago, when the weather outside changed. She said she had already reported it to the CNAs, nursing staff and to the maintenance director but nothing had been done (did not remember when she had reported). She said she had not felt any respiratory distress due to the temperature in her room and thought it was because she was receiving oxygen therapy and had her two fans on all the time. She said she had not gone to the hospital or had any medical emergencies due to her room being too hot. During an observation on 04/04/25 at 1:15 p.m. with the Maintenance Director and using his infrared Page 1 of 3 676391 676391 04/04/2025 Windsor Calallen 4162 Wildcat Dr Corpus Christi, TX 78410

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few thermometer, Resident #1's room temperature registered at 81.6 degrees. He said the resident rooms should be between 71 to 81 degrees. In an interview on 04/04/25 at 1:40 pm., CNA A said for past couple of days, she had felt the temperature in Resident #1's room was warmer than other rooms (in the same hall). She said Resident #1 had not complained of the temperature in her room, and thought it was because she had two fans directly in front of her on all the time. CNA A said she mentioned the temperature in Resident #1's room to CNA B earlier that day and CNA B told her she had already reported it to their Charge Nurse, RN C. CNA A said since CNA B had already reported it, she did not report it to anyone else. In an interview on 04/04/25 at 1:50 p.m., CNA B said she had noticed Resident #1's room had been hot the past 2 days. She said she had reported it to RN C earlier that day. She said Resident #1 had two fans directly in front of her bed that helped circulate the air. CNA B said Resident #1 was on continuous oxygen therapy. In an interview on 04/04/25 at 1:58 p.m RN C said CNA B had mentioned to him earlier that day that Resident #1's room seemed warmer compared to the other rooms in Hall 400. He said CNA B mentioned it in a casual conversation they had about something else and he did not taken it as a concern. He said he could not remember if he had reported it to the Maintenance Director or to his ADON. He was not able to say what negative outcome if any to Resident #1 if her room was too hot. In an interview on 2:10 p.m., the Maintenance Director said he checked the temperature in all 6 halls every morning and logged them in the facility's temperature log. He said he had not encountered any concerns regarding the temperatures in the halls in the past month. He said he would not check the temperature in the resident's room unless a concern was reported. He said he had not received any concerns regarding the temperature in Resident #1's room. He said the air condition that would cool Resident #1's room had not been serviced in 12 months. In an interview on 04/04/25 at 2:00 p.m., the ADON said she had not received any concerns regarding Resident #1's room temperature. She said each resident had what they called guardian angels that were assigned to them. She said the guardian angels would visit their residents daily. An interview on 04/04/25 at 3:25 p.m., CMA F said had noticed Resident #1's room was humid the past couple of days. She said Resident #1 was continuous oxygen therapy and the temperature in the room could make it uncomfortable for her. She said she had not reported it to anyone because she did not think it could negatively affect Resident #1. An interview on 04/04/25 at 3:45 p.m., the Medical Records/Guardian Angel said her responsibilities as a guardian angel were to visit her assigned residents daily. She said during those visits, she would ensure their room was safe and comfortable. She said she had noticed Resident #1's room was stuffy which she said was not normal the past 2 days. She said she had verbally reported it to the Maintenance Director on 04/03/25 and 04/04/25 but the Maintenance Director did not acknowledge her. She said she had not reported it to anyone else. Record review of Resident #1's medical electronic record reflected she had not had a change in condition or had been transferred to the local hospital in the past 2 weeks. Record review of the facility's air temperature-daily morning inspection log reflected the temperature in hall 400 was between 72 and 73 degrees from 03/01/25 to 04/04/25. 676391 Page 2 of 3 676391 04/04/2025 Windsor Calallen 4162 Wildcat Dr Corpus Christi, TX 78410

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 04/04/25 at 4:00 p.m., the Administrator said he had not received any concerns regarding Resident #1's room temperature. He said the Maintenance Director would check the temperature in all six halls daily and would keep a log. He said he did not review the logs unless there was a concern. He said the Maintenance Director would not go into any resident rooms when checking the temperature in the halls. The Administrator said he had personally checked Resident #1's room temperature at 1:45 p.m. with the Maintenance Director infrared thermostat and verified the temperature was 81.6 degrees. He said he had immediately instructed the Maintenance Director to install a window unit in Resident #1's room. He said Resident #1 had not voiced any concerns about her room temperature to him. The Administrator said there were no negative outcome to Resident #1 for having her room temperature at 81.6 degrees since she had two fans. The Administrator said the facility did not have a policy related to room temperatures. 676391 Page 3 of 3