Health inspection·August 8, 2024

42 CFR §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81°F. 22 CCR §72657 Heating, air conditioning and ventilating systems shall be maintained in normal operating conditions to provide a comfortable temperature and shall meet the requirements of Section T17-105, Title 24, California Administrative Code. 22 CCR §72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/24/2024, the California Department of Public Health (CDPH), received a complaint alleging the air conditioning (A/C) unit was not working and the residents’ rooms were very hot. The complaint alleged this was had been an ongoing issue for a week and the facility was not addressing the issue, nor providing water to residents. On 6/25/2024 at 11:30 a.m., an unannounced visit was conducted at the facility. Upon investigation, the A/C unit was not working in 9 resident rooms which was occupied by 34 residents. The facility failed to: 1. Maintain residents’ room temperatures in a range of 71 to 81 degrees (unit of measurement) Fahrenheit (F, a scale of temperature) for 9 resident rooms (Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136). 2. Implement the facility’s contingency plan (involves making various decisions as an organization before an emergency happens) when the A/C unit became inoperable on 6/22/2024 affecting Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136. 3. Implement cooling measures to keep residents comfortable for Resident 1, 2, 12, 13, 25, 26, 27, 28, 29, and 30 when the A/C unit became inoperable on 6/22/2024, a total of 3 days. These deficient practices placed the residents in the affected rooms at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures) and had the potential to negatively affect the identified 34 residents. 1. During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed awake in bed, nonverbal. Resident 1 was observed with, dry, cracked lips.  A review of Resident 1’s Admission Record indicated Resident 1 was a 71-year-old female admitted to the facility on 6/8/2018. Resident 1’s admitting diagnosis included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dementia (impaired ability to remember, think, and make decisions which interferes with everyday activities), and type two (2) diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/12/2024, indicated Resident 1 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 1 required total assistance (helper does all the effort) with oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. During an interview on 6/25/2024, at 12:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1’s lips looked “a little dry”. During an interview on 6/25/2024, at 2:02 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1’s room was hot. During an interview on 6/25/2024, at 3:15 p.m., with Resident 1’s Family Member (FM) 1, FM 1 stated the past 7 days, between 3 p.m., to 6 p.m., she observed Resident 1’s room was hot more than usual. FM 1 she complained to a nurse but did not know the nurse’s name.  During an interview on 6/25/2024, at 5:50 p.m., with FM 1, FM 1 stated she had not witnessed staff offering any of the residents in Resident 1’s room water, popsicles, ice cream, or other cooling foods. 2. During a concurrent observation and interview on 6/25/2024, at 12:04 p.m., with Resident 2 (Resident 1’s roommate), Resident 2 was observed awake, alert, and seated on a wheelchair. Resident 2 stated the air conditioning in their room had not been working since last week. Resident 2 stated it was so humid around 5 p.m. every day since the air conditioner stopped working last week that she could not breathe. A review of Resident 2’s Admission Record indicated Resident 2 was a 52-year-old female originally admitted to the facility on 3/20/2020, and most recently re-admitted Resident 2 on 11/03/2020. Resident 2’s admitting diagnosis included anxiety disorder (a disorder involving persistent and excessive worry that interferes with daily activities), and gastro-esophageal reflux disease ([GERD] a condition in which the stomach contents move up into the esophagus). A review of Resident 2’s MDS, dated 6/22/2024, indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required moderate assistance (the helper does less than half the effort) with toileting hygiene, dressing the lower body, and putting on/taking off footwear. During an interview on 6/25/2024, at 3:55 p.m., with Resident 2, Resident 2 stated she was concerned about her roommate (Resident 1) because she could not ask for help. Resident 2 stated other than today (6/25/2024), in the activities room, no one offered her popsicles, ice cream, or any other cool foods to decrease the effects of the heat. 3. During a concurrent observation and interview on 6/25/2024, at 12:59 p.m., with Resident 12, Resident 12 was observed awake, alert, and in bed. Resident 12 stated it felt too hot and he had been uncomfortable. Resident 12 stated he reported the warmer temperature to unknown nursing staff a few days prior but they did not do anything about it. Resident 12 stated the room felt much hotter late in the afternoon. A review of Resident 12’s Admission Record indicated Resident 12 was a 71-year-old male originally admitted to the facility on 7/18/2021, and most recently re-admitted Resident 12 on 5/25/2022. Resident 12’s admitting diagnosis included sepsis (infection of the blood) due to Escherichia coli ([E. Coli] a type of bacteria that causes disease in humans) and type 2 diabetes mellitus. A review of Resident 12’s MDS, dated 4/25/2024, indicated Resident 12 was moderately cognitively impaired. The MDS indicated Resident 12 required total assistance with showering/bathing.  4. During an observation and concurrent interview on 6/25/2024, at 1:41 p.m., with Resident 13, Resident 13 was observed awake, alert, and sitting on a wheelchair in the hallway, outside of his room. Resident 13 stated he was in the hallway because his room was too hot and had been so hot for a couple of days. Resident 13 stated he was going to buy a fan, to help keep him cool since no one was addressing the problem. A review of Resident 13’s Admission Record indicated Resident 13 was a 45-year-old male admitted to the facility on 4/28/2023. Resident 13’s admitting diagnosis included type 2 diabetes mellitus and chronic kidney disease (when the kidneys do not function normally and have difficulty filtering waste from the blood). A review of Resident 13’s MDS, dated 5/5/2024, indicated Resident 13 was cognitively intact. The MDS indicated Resident 13 required maximum assistance for toileting hygiene, showering/bathing, dressing the lower body, and putting on/taking off footwear.  5. During a concurrent observation and interview on 6/25/2024, at 3:48 p.m., with Resident 25, Resident 25 was observed awake, alert, and in bed. Resident 25 stated it had been very hot in the facility for a couple of days and wished it was colder. Resident 25 stated none of the staff offered her popsicles, ice cream, or any cool foods since it had been hot. Resident 25 stated she felt staff do not care which made her feel sad. A review of Resident 25’s Admission Record indicated Resident 25 was an 85-year-old female admitted to the facility on 5/28/2024. Resident 25’s admitting diagnosis included an unstageable (unable to determine the depth due to abnormal tissue covering healthy tissue) pressure ulcer (damage to an area of the skin or tissues because of constant pressure on the area for a long time) of the sacral region (lower back), and type 2 diabetes mellitus. A review of Resident 25’s MDS, dated 6/4/2024, indicated Resident 25 was moderately cognitively impaired. The MDS indicated Resident 25 required total assistance with showering/bathing, dressing the lower body, and putting on/taking off footwear. 6. During an interview on 6/26/2024, at 2:22 p.m., with Resident 26, Resident 26 stated his room was “too hot” on 6/25/2024, in the afternoon. Resident 26 stated staff did not offer him any foods like popsicles or ice cream the past week, to keep him cool. Resident 26 stated he asked the nurses (names unknown) to pat him down with a cold wet towel. diagnosis included type 2 diabetes mellitus, sepsis, and acute respiratory failure (the i A review of Resident 26’s Admission Record indicated Resident 26 was a 41-year-old male admitted to the facility on 1/21/2023 with diagnoses including hypoxia (low oxygen in the blood). A review of Resident 26’s MDS, dated 4/25/2024, indicated Resident 26 was cognitively intact. The MDS indicated Resident 26 had required total assistance with oral hygiene, toileting hygiene, showering/bathing, dressing the upper and lower body, and personal hygiene. 7. During an interview on 6/26/2024, at 3:18 p.m., with Resident 27, Resident 27 stated yesterday (6/25/2024), her room was too hot and had been very hot for one week. Resident 27 stated she told multiple nurses on multiple occasions. Resident 27 stated she did not recall the names of the nurses she told. Resident 27 stated when she told one nurse the heat was too much the nurse stated, “it is a very hot day”. Resident 27 stated staff did not offer him any cooling measures such as popsicles or ice cream. Resident 27 stated she drank cold water and fanned herself to keep cool. Resident 27 stated she was uncomfortable due to the heat. Resident 27 stated her roommate (Resident 28) was sweating a lot, and the nurses had to change her (Resident 28’s) sheets because she was drenched in sweat. A review of Resident 27’s Admission Record indicated Resident 27 was a 79-year-old female originally admitted to the facility on 8/24/2016, and most recently re-admitted Resident 27 on 5/29/2023. Resident 27’s admitting diagnosis included type 2 diabetes mellitus and acute respiratory distress syndrome ([ARDS] a condition in which fluid collects in the lungs’ air sacs, depriving organs of oxygen). A review of Resident 27’s MDS, dated 5/16/2024, indicated Resident 27 was cognitively intact. The MDS indicated Resident 27 had required maximum assistance with toileting hygiene, showering/bathing, and dressing the lower body. 8. A review of Resident 28’s Admission Record indicated Resident 28 was a 57-year-old female originally admitted to the facility on 8/2/2022, and most recently re-admitted Resident 28 on 10/29/2023. Resident 28’s admitting diagnosis included metabolic encephalopathy (a chemical imbalance in the blood effecting the brain) and type 2 diabetes mellitus. A review of Resident 28’s MDS, dated 6/6/2024, indicated Resident 28 was severely cognitively impaired. The MDS indicated Resident 28 required total assistance with toileting hygiene, and showering/bathing. 9. During an interview on 6/26/2024, at 3:45 p.m., with Resident 29, Resident 29 stated her room had been hot the past week and she had not been offered popsicles, ice cream, or other cold snacks.  A review of Resident 29’s Admission Record indicated Resident 29 was a 62-year-old female admitted to the facility on 2/14/2024. Resident 29’s admitting diagnosis included fracture (broken) to the left pubis (a part of the hip bone), fracture of the sacrum (lower back bone). A review of Resident 29’s MDS dated 5/21/2024, indicated Resident 29 was cognitively intact. The MDS indicated Resident 29 had required maximum assistance with toileting hygiene, showering/bathing, dressing the lower body, and putting on/taking off footwear. 10. During a concurrent observation and interview on 6/26/2024, at 4:08 p.m., with the Housekeeping Supervisor (HS), Resident 30 was observed in bed, asleep. A thermometer reading measured 81.9 degrees. Resident 30’s air conditioning vent was closed. The HS stated she was going to open the vent to help cool the room. A review of Resident 30’s Admission Record indicated Resident 30 was a 93-year-old female originally admitted to the facility on 8/8/2021, and most recently re-admitted Resident 30 on 1/16/2024. Resident 30’s admitting diagnosis included dementia and chronic kidney disease. A review of Resident 30’s MDS, dated 4/15/2024, indicated Resident 30 was severely cognitively impaired. The MDS indicated Resident 30 had required total assistance with oral hygiene, toileting hygiene, showering/bathing, dressing both the upper and lower body, and personal hygiene.  During an interview on 6/25/2024, at 9:12 a.m., with the DOM, the DOM stated the air conditioning unit affecting rooms 128 through 138 stopped working on 6/20/2024. The DOM stated the residents’ rooms and community areas must be between 71 to 81 degrees F. During an interview on 6/25/2024, at 1:58 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated it had been “crazy hot” for the past few days. CNA 1 stated when he gave residents showers, he was sweating. During an observation, on 6/25/2024, at 3:06 p.m., with the Director of Maintenance (DOM), the temperature in room 130 was 84 degrees Fahrenheit (F), room 131 was 81.5 degrees F, room 132 was 84 degrees F, room 134 was 84 degrees F, room 135 was 81.5 degrees F, and room 136 was 84 degrees F. During a concurrent observation and interview, on 6/25/2024, at 3:45 p.m., with the DOM, the DOM stated residents’ room temperatures were as follows: room 128 was 82 degrees F, room 129 was 82 degrees F, room 130 was 85 degrees F, room 132 was 84.5 degrees F, room 133 was 81.5 degrees F, room 134 was 86.5 degrees F, and room 136 was 84.5 degrees F. The DOM stated the room temperatures were above the regulated range which could cause discomfort to residents. During an interview on 6/25/2024, at 4:12 p.m., with the Director of Staff Development (DSD), the DSD stated the staff first started complaining of the heat on 6/19/2024. The DSD stated the facility was going to purchase fans for the residents’ rooms without functioning air conditioning that day (6/25/2024). The DSD stated if residents get too hot, they could suffer from heat stroke. During an interview on 6/25/2024, at 4:21 p.m., with the DOM, the DOM stated the compressor on the air conditioner was replaced on 6/20/2024 by the Repair Vendor, but it stopped working again 6/21/2024. The DOM stated the facility took temperatures of the residents’ rooms daily in the morning. The DOM stated on 6/25/2024, staff had not taken temperatures from 3:00 p.m. to 5:00 p.m., which unfortunately was the hottest part of the day.  During a concurrent observation and interview, on 6/25/2024, at 4:32 p.m., with the DOM, the DOM stated the temperatures in room 128 was 81.5 degrees F, room 130 was 83 degrees F, room 132 was 84 degrees F, room 133 was 81.5 degrees F, room 134 was 86.5 degrees F, and room 136 was 85 degrees F. During an interview on 6/25/2024, at 6:35 p.m., with the DSD, the DSD stated the facility did not have a contingency plan in place to use if the air conditioner stopped working. The DSD stated the facility did not report the air conditioning ceasing to work to any the state or federal agencies. During an interview on 6/25/2024, at 6:36 p.m., with the DOM, the DOM stated the facility did not have a contingency plan for when the air conditioner turned off. and The DOM stated the facility did not have a Preventative Maintenance ([PM] log to keep track of preventative maintenance efforts to prevent the air conditioning system from not working) log. The DOM stated the only PM log the facility had was of the room temperatures. A review of the facility’s resident room temperature log, dated 6/2024, indicated on 6/5/2024 through 6/10/2024, 6/15/2024, and on 6/22/2024 through 6/24/2024 the temperatures of residents’ rooms were n