Health inspection·September 11, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure the facility's temperature was in an acceptable range as indicated, in the facility's policy and procedure (P&P), titled, Homelike Environment, for six resident's rooms, one dining room, and one hallway out of 23 resident's rooms, two dining rooms, and two hallways. This deficient practice had the potential to place the residents, visitors, and staff members at risk for serious illness, harm, and/or death. Findings: During an interview on 9/10/2024 at 4:29 PM with the Director of Nursing (DON), the DON stated the facility's air conditioner for the middle part of the nursing unit was broken. The DON stated the air conditioner had malfunctioned since 9/9/2024. The DON stated they started fixing it this morning (9/10/2024) and were providing fans to the residents. During a concurrent observation and interview on 9/10/2024 at 4:40 PM with the Maintenance Director 1 (MD 1), MD 1 stated the facility's acceptable temperature range was 71 to 81 degrees Fahrenheit (F, temperature scale). During an observation, the following temperatures were observed: 1. room [ROOM NUMBER] was 88.2 degrees F 2. room [ROOM NUMBER] was 86.4 degrees F 3. Dining room [ROOM NUMBER] was 84.4 degrees F 4. room [ROOM NUMBER] was 89.1 degrees F 5. Station 1 hallway 91.9 degrees F 6. room [ROOM NUMBER] 94.6 degrees F 7. room [ROOM NUMBER] was 97 degrees F 8. room [ROOM NUMBER] was 94.1 degrees F During the same concurrent observation and interview on 9/10/2024 at 4:40 PM, MD 1 stated the HVAC Page 1 of 2 555106 555106 09/11/2024 Santa Fe Lodge 5053 Peck Rd. El Monte, CA 91732

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some technician (HVACT 1, Heating, Ventilation and Air Conditioning professional who installs and repairs various home heating and cooling systems), was there and was working on replacing the condenser (the outdoor component of an AC unit that is responsible for the condensation process that releases heat). MD 1 stated if the temperature was high, it meant that the circulating air was not flowing through. MD 1 stated the air conditioner was going to be fixed that same day (9/10/2024) and it malfunctioned on 9/9/2024 around 3 PM to 5 PM. During an interview on 9/10/2024 at 5:36 PM with the HVACT 1, HVACT 1 stated the air conditioner was fixed now. HVACT 1 stated the air conditioner was repaired and was in working condition. During an interview on 9/11/2024 at 9:14 AM with MD 1, MD 1 stated the facility had three air conditioning units. MD 1 stated Rooms 8, 10-19, showers, and closet were connected to the Unit 2 air conditioner. MD 1 stated Unit 2 was the affected air conditioning unit. During an interview on 9/11/2024 at 4:15 PM, with MD 1, MD 1 stated if the facility's air conditioner was not working, residents would be at risk for dehydration, heatstroke, heat exhaustion, and breathing issues. MD 1 stated it was important to have the facility's air conditioner working for the circulation of air and for the well-being of the residents to be in their comfortable zone. During a review of the facility's P&P, titled, Homelike Environment, revised February 2021, the P & P indicated, the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable and safe temperatures (71F-81F). During a review of the Maintenance Supervisor's Job Description (JD), dated January 27, 2022, the JD indicated, the Maintenance Supervisor would be responsible for the facility being maintained in good repair at all times, including interior and exterior surfaces, fixtures, and mechanical systems. 555106 Page 2 of 2