**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed for one of two sampled residents (Resident 2), to protect the resident ' s rights to be free from physical abuse by a resident, when a resident (Resident 1), diagnosed with dementia, and anxiety with no identified behavioral triggers, was moved rooms multiple times due to intolerance to noise without assessing the resident ' s individual needs. The failure of the facility in assessing resident ' s need for appropriate room placement resulted in Resident 1 assaulting Resident 2 who exhibited frequent moaning, mumbling, and yelling. Resident 2 sustained lacerations (a cut in the skin) to the head, extensive facial fractures (a break in a bone), two right rib fractures and L1 vertebra fracture (a break on the first bone on the lower back) and later passed away in the hospital. On May 13, 2025, at 4:45 p.m., the Administrator (ADM) and Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ- situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to assess residents ' needs and preferences during room changes. Resident 1 ' s preferences of a quiet room was not assessed, and his care plan was not revised to ensure his needs were met. On May 14, 2025, at 9:30 a.m., the ADM and DON were notified an extended survey would be conducted due to the substandard quality of care issues. On May 14, 2025, at 5:25 p.m., the ADM and DON presented an acceptable IJ removal plan. On May 14, 2025, at 6:03 p.m., the immediate jeopardy was removed in the presence of the ADM and the DON, upon verification of the implementation of the IJ removal plan. Findings: On May 9, 2025, Resident 2 ' s admission record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), impulse disorder (a mental health condition) and hospice care services (specialized end-of-life care). A review of Resident 2's History and Physical, dated April 9, 2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Minimum data Set (MDS-an assessment tool), dated March 25, 2025, indicated a Brief Interview for Mental Status (BIMS - a tool used to identify the cognitive condition of a resident) score of 3 (severe cognitive impairment). A review of Resident 2's IDT (Interdisciplinary Team) Note, dated May 8, 2025, indicated, at 2 a.m. on 5/8/2025, a Certified Nursing Assistant (CNA) visited Resident 2 in his room and found him with blood stain on his face and both hands. The document further indicated it was reported immediately to the charge nurse and 911 was called. The police department, hospice services, physicians, the California Department of Public Health (CDPH), long term care Ombudsman (resident advocate) and the family were notified, and Resident 2 was transferred to the hospital for further treatment. A review of Resident 2's Nurse ' s Note, documented by Licensed Vocational Nurse (LVN) 1, on May 8, 2025, at 3:22 a.m., indicated that on May 8, 2025, at 2 a.m., a CNA went to the nursing station and reported there was a blood bath in Resident 2 ' s room. The document further indicated, the staff found Resident 2 in bed lying on his right side, awake, and was responsive to touch and noted to have lacerations to both sides of his face, hands, and arms. There was blood noted on Resident 2 ' s pillow and on the ceiling and wall away from his immediate bed area. The document further indicated, staff called 911 and the incident was reported to the local police department. At approximately 2:15 a.m., police arrived and assessed the residents and questioned the suspected abuser in bed A (Resident 1). At 2:25 a.m., the paramedics arrived and took Resident 2 to a local hospital. Staff made police and paramedics aware that Resident 2 was on hospice care. A review of Resident 2's Social Service Notes, dated May 8, 2025, at 9:55 a.m., indicated, .resident (Resident 2) was transfer to (initials of hospital) due to altercation with roomate (sic) overnight . A review of Resident 2's Care Plan, dated June 10, 2022, indicated, .Problem with behavior related to socially inappropriate/disruptive behavior manifested by constant shouting .Goal: Will have 0-1 episode of constant crying daily x3 months .Interventions: observe and assess for possible cause of shouting and intervene immediately .report to MD if with uncontrollable shouting . A review of Resident 2 ' s Emergency Department Note - Physician, dated May 8, 2025 at 5:36 a.m., indicated, .exam reveals extensive complex laceration ranging from right forehead across the bridge of the nose to the left eyelid .nose is unstable .bilateral (both) eyes are swollen shut .when opened there is severe chemosis (eye swelling) .ecchymosis (bruising) to the chest .small laceration to the upper gum .patient has extensive facial fracturing .has an inferior (below) blowout fracture on the right .with muscle protrusion (sticking out) .rib fractures .and fracture of L1 (lumbar area - lower part of back) vertebra . On May 9, 2025, Resident 1' s admission record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and a history of being a registered sex-offender on parole (an individual convicted of a sex crime required to register with law enforcement and released from prison under parole supervision) and wore an ankle bracelet (a device used to track the location and movements of an individual under the supervision of the criminal justice system) for monitoring. A review of Resident 1's History and Physical, dated January 15, 2025, indicated Resident 1 has the capacity to make needs known but not able to make medical decisions. A review of Resident 1's MDS, dated [DATE], indicated a BIMS score of 3 (severe cognitive impairment). A review of Resident 1's IDT Note, dated May 8, 2025, indicated at around 2 a.m., a report of an unwitnessed interaction occurred in Resident 1 ' s room. Resident 1 was found on his bed, covered with the sheet and refused to be assessed and interviewed. There was blood stain noted on the wall and ceiling in the room, and both Residents 1 and 2 were lying on their beds. The document further indicated the two residents (Residents 1 and 2) had no prior history and Resident 1 had no prior history of aggressive behaviors towards Resident 1. During interview with the law enforcer, Resident 1 admitted hitting Resident 2 because he made too much noise. Resident 1 was taken into custody by the local police department. A review of Resident 1's eINTERACT Change of Condition, dated May 8, 2025, indicated, at around 2 a.m., a CNA reported a blood bath in Resident 1 ' s room. Resident 1 was lying face down in bed with sheet covering his entire body, and he refused to be interviewed and assessed by LVN. Staff called 911 and police. The document further indicated Resident 1 was interviewed, and he stated he (Resident 2) makes too much noise, and I hit him. The document further indicated Resident 1 was observed to have blood on his hands and body and was escorted by the police. A review of Resident 1's Care Plan, dated December 12, 2024, indicated, .Resident is at risk for physical and verbal aggression r/t Dementia, and is a registered sex offender on parole, wears an ankle bracelet .Goal: Will have no evidence of behavior problems by review date .Interventions: monitor behavior episodes and attempt to determine underlying cause .consider location, time of day, persons involved, and situations .document behavior and potential causes . Further review of Resident 1 ' s records indicated that he had room changes, since admission, on the following dates: - 1/24/25 - moved from 14A to 19A - 1/26/35 - moved from 19A to 31A - 2/13/25 - moved from 31A to 19A - 3/1/25 - moved from 19A to 14B - 3/19/25 - moved from 14A to 25A - 5/5/25 - moved from 25A to 34B - 5/7/25 - moved from 34B to 31B - 5/8/25 - moved from 31B to 30A On May 9, 2025, at 2:11 p.m., Resident 3 was interviewed. Resident 3 stated three days ago, Resident 1 was his roommate and then was transferred to another room. Resident 3 stated, Resident 1 yelled at him regarding his music and got out of bed as if he was going to come at me. Resident 3 stated, Resident 1 stood at him and with clenched fist. Resident 3 stated, the Licensed Vocational Nurse (LVN) 2 overheard and intervened. On May 9, 2025, at 3:05 p.m., LVN 2 was interviewed. LVN 2 stated Residents 1 and 3 used to be roommates before. LVN 2 stated he recalled Resident 1 complained about Resident 3 ' s loud television and radio and he had to intervene because Resident 1 became upset at Resident 3. LVN further stated, he notified the Director of Nursing (DON) and Resident 1was moved to a different room due to the roommate's (Resident 3) noise. On May 9, 2025, at 4:32 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 1 recently had been upset about his ankle bracelet and would refuse to charge it. CNA 1 stated she was instructed to report any changes in Resident 1 ' s behavior to the charge nurses. CNA 1 stated, she knew Resident 1 and he did not like noise. CNA 1 further stated, it was a terrible idea to place him in the same room with Resident 2 who constantly moaned and yelled. On May 12, 2025, at 3:22 p.m., a concurrent interview and records review of Resident 1 ' s room change forms was conducted with the Case Manager. The CM stated nursing staff would let her know if there was a room change request, and she would complete a room change form for the residents. The CM stated nursing would assess for compatibility, and she would only write the resident ' s names on the form and indicate the old and new room numbers for each resident. The CM stated she did not know the reasons of why Resident 1 had those room changes. The CM stated there were no assessments or reason of the move documented on the forms. The CM further stated it would help to have them written on the forms to help track the room changes and avoid any problems with incompatibilities. On May 13, 2025, at 10:09 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated room change process included identifying the reasons for the move and assessing for compatibility. RN 1 stated staff were conducting assessments, but not documenting the assessments or the reason for the room change in the residents ' records. RN 1 stated staff should have identified that Resident 1 did not like noise and should not have been placed with Resident 2 who constantly moaned and yelled. RN 1 further stated, staff should have documented the assessments and reason for moving Resident 1 to a new room to make staff aware of any incompatibilities and avoid any arguments or harm. On May 13, 2025, at 10:20 a.m., a concurrent interview and record review of Resident 1 ' s room changes since admission were conducted with the DON. The DON stated there were no documented evidence room preference and assessments conducted for Resident 1. The DON further stated, there were no documentation of the reasons for moving Resident 1 into a new room on his records and on the room change forms for all the room changes that had occurred for Resident 1. The DON further stated staff should have been documenting them to track compatibility and identify any issues between Resident 1 and other residents; and to avoid an altercation or injury. A review of facility policy and procedures titled Room Change, revised 2021, indicated, .changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change .resident preferences are taken into account when such changes are considered .the patients involved with room change will be assessed by facility staff for compatibility and appropriateness .final approval for room changes will be approved by DON, if DON is not available, MDS or RN Supervisor will provide final approval .documentation or a room change is recorded in the resident ' s medical records .inquiries concerning room changes should be referred to the administrator . A review of facility policy and procedures titled Resident-to-Resident Altercations, revised September 2022, indicated, .all altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff .behaviors that may provoke a reaction by residents or others include .physically aggressive behavior, such as hitting, kicking, grabbing .pushing/shoving .threatening gestures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On August 5, 2024, at 5:15 P.M., during a concurrent observation in Resident 17's room and interview with Resident 17, Resident 17 was observed lying in bed, awake. Resident 17 stated she felt hot. Resident 17 stated she had spoken to her Family Member (FM) about her concerns related to the room temperature. On August 5, 2024, at 5:19 P.M., an observation with a concurrent interview was conducted with the MS. The MS used a thermometer gun to check the room temperature in Resident 17's room. The MS pointed the thermometer gun at the wall above Resident 17's headboard which showed a temperature of 91 degrees Fahrenheit. The MS stated the required comfortable room temperature was from 71 degrees Fahrenheit to 81 degrees Fahrenheit. The MS stated Resident 17's room temperature was not good. On August 6, 2024, at 8:45 A.M., an interview was conducted with Resident 17's FM. The FM stated the room temperature in Resident 17's room was uncomfortable since early June 2024. The FM stated the room temperature in Resident 17's room was hot and uncomfortable. The FM further stated the temperature in Resident 17's room was hot and uncomfortable and Resident 17 had complained about the heat, which made it difficult for her to breathe properly. The FM stated the air conditioner (AC) felt like it was blowing hot air which made Resident 17 uncomfortable in her room. The FM stated she was unaware if the facility staff had offered Resident 17 a room change. On August 7, 2024, Resident 17's admission RECORD was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), anxiety (type of mental disorder), diabetes (high blood sugar), and hypertension (high blood pressure). A review of Resident 17's Minimum Data Set, dated June 19, 2024, indicated Resident 17's BIMS score was 8 (moderate cognitive impairment). 6. On August 5, 2024, at 5:20 P.M., a concurrent observation and interview was conducted with Resident 32 in her room. Resident 32 was observed sitting on the edge of bed and was awake. Resident 32 stated it had been hot in the room for the past month and the fan was not helping. Resident 32 stated the room temperature was unusually hot and the facility had never offered a room change due to the increased room temperature. Resident 32 stated she was not aware of any issue with the AC units. On August 5, 2024, at 5:22 p.m., an observation with a concurrent interview were conducted with the MS. The MS used a thermometer gun to check the room temperature in Resident 32's room. The MS pointed the thermometer gun at the wall above Resident 32's headboard. The thermometer gun read the temperature at 90.5 degrees Fahrenheit. The MS stated the required comfortable room temperature was from 71 degrees Fahrenheit to 81 degrees Fahrenheit. The MS stated Resident 32's room temperature was not good. On August 7, 2024, Resident 32's 'admission RECORD was reviewed. Resident 32 was admitted to the facility on [DATE], with a diagnosis that included bilateral osteoarthritis of knee (bone disease of both knees), fibromyalgia (a chronic disorder that causes widespread pain and tenderness in the body), dementia, and depression (feeling of hopelessness). A review of Resident 32's MDS, dated July 3, 2024, indicated Resident 32's BIMS score was 15 (cognitively intact). 7. On August 5, 2024, at 5:23 p.m., a concurrent observation and interview were conducted with Resident 48 in his room. Resident 48 was observed lying on bed and was awake. Resident 48 stated the temperature in the room was hotter than usual and this was the first time he had experienced such high temperatures. Resident 48 stated staff had never offered any help or a room change due to increased room temperature. On August 5, 2024, at 5:23 p.m., an observation with a concurrent interview were conducted with the MS. The MS used a thermometer gun to check the room temperature in Resident 48's room. The MS pointed the thermometer gun at the wall above Resident 48's headboard which showed a temperature of 88.7 degrees Fahrenheit. The MS stated the required comfortable room temperature range is from 71 degrees Fahrenheit to 81 degrees Fahrenheit. The MS stated Resident 48's room temperature does not meet required criteria for a safe room temperature. On August 7, 2024, Resident 48's admission RECORD was reviewed. Resident 48 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction (disrupted blood flow in the brain) with left sided deficit (weakness), diabetes mellitus (abnormal blood sugar), morbid obesity, depression (feeling of sadness), and cardiomegaly (enlarged heart). A review of Resident 48's MDS, dated June 18, 2024, indicated Resident 48's BIMS score was 13 (cognitively intact). 8. On August 5, 2024, at 5:24 p.m., a concurrent observation and interview were conducted with Resident 53 in his room. Resident 53 was observed lying on bed and was awake. Resident 53 stated the temperature in the room had been hot for the past two months and the staff had not offered assistance, or a room change despite the increased temperature. Resident 53 stated he had told nursing staff multiple times over the past month about the discomfort, but no help was offered. Resident 53 stated he was not aware of any issues related to the AC. Resident 53 became agitated and yelled at the MS due to the extreme heat and the lack of information about why the temperature was elevated. On August 5, 2024, at 5:25 p.m., a concurrent observation and interview were conducted with the MS. The MS was observed using the thermometer gun to check the temperature above Resident 53's bed. The thermometer gun recorded a temperature of 87.3 degrees Fahrenheit. A review of the facility's policy and procedure titled, Quality of Life-Homelike Environment, dated 2002, indicated, .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .Comfortable and safe temperatures (71°F - 81°F) . A review of the undated facility's policy and procedure titled, Providing Comfortable and Safe Temperature Levels for Residents, indicated, .It is the policy to provide comfortable and safe temperature levels for the residents. The facility will maintain a temperature range of 71-81° F .The facility will follow regulations and maintain an acceptable temperature level for the residents. The facility will measure the air temperature above floor level in resident rooms, dining areas, and common areas. If the temperature is out of the 71-81-degree range, the staff will report this to the maintenance department who then will check the system. Actions will be taken by maintenance department and staff when residents complain of heat or cold, e.g., check and fix air conditioning system .provide extra fluids during heat waves . Based on observation, interview and record review, the facility failed to ensure a comfortable environment was provided, for eight of eight residents (Residents 40, 36, 28, 15, 17, 32, 48, and 53), when the temperature in the resident's rooms were above 81 degrees Fahrenheit. On August 5, 2024, at 7:51 p.m., the Administrator (ADM), the Director of Nursing (DON), and the Director of Staff Development (DSD), were verbally notified of the Immediate Jeopardy (IJ-situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death, to a resident), due to the facility's failure to provide a comfortable environment for eight residents (Residents 40, 36, 28, 15, 17, 32, 48, and 53) when the resident's room temperature were above 81 degrees Fahrenheit. These failures resulted in the discomfort for Residents 40, 36, 28, 15, 17, 32, 48, and 53, particularly for Resident 17 who could not breathe properly and for Resident 53 who experienced agitation. In addition, this failure had the potential for the residents to experience exacerbation of respiratory and chronic illnesses. On August 6, 2024, 10:36 a.m., the facility presented an acceptable plan of actions which included the following: -The facility purchased additional five large swamp coolers and 10 free standing air-conditioning (AC) units on August 5, 2024. The swamp coolers (a device that cools air through the process of evaporation [liquid turns to gas])were placed in the hallways and the free-standing AC were placed in the hot and uncomfortable residents' rooms. -The facility identified the affected residents (Residents 15, 40, 36, 28, 17, 32, 53, and 48) and were assessed and monitored for adverse effects. -The facility-initiated room temperature checks in the affected resident rooms on August 5, 2024, starting 8 p.m., then every two hours and documented in the temperature log. -The facility staff will provide hydration every two hours from 10 a.m. to 8 p.m. -The ADM signed a contract to replace the AC units on August 6, 2024, and scheduled to install the AC units on August 13 to 15, 2024. -The affected residents will be interviewed by the activities staff during morning shift and the Certified Nursing Assistants (CNAs) during afternoon and evening shifts. If the resident's room temperature will not be controlled, the facility will provide room changes and close the affected rooms until the new AC will be installed. If there will be no available beds to accommodate room changes, the facility will utilize emergency transfer to other facilities. -New window treatment heat reduction film/tint will be placed on the windows and sliding doors of affected rooms on August 6, 2024; and -The ADM will report average room temperature levels in the affected rooms every quarterly Quality Assurance (QA) meeting. On August 6, 2024, at 1:52 p.m. the Immediate Jeopardy was removed in the presence of the ADM, upon onsite verification of the implementation of the plan of actions. On August 6, 2024, at 2:03 p.m., the ADM was notified an extended survey would be conducted due to the substandard quality of care issues. Findings: 1. On August 5, 2024, at 10:56 a.m., an observation and interview with Resident 40 was conducted. Resident 40 was observed sitting up at the side of the bed watching television. Resident 40 stated it was warm in her room. On August 6, 2024, Resident 40's admission RECORD was reviewed. Resident 40 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (mental health condition associated with emotional highs and lows), hypertension (high blood pressure), and anxiety (feelings of worry about something of an uncertain outcome). A review of Resident 40's Minimum Data Set (MDS - an assessment tool), dated February 8, 2024, indicated a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact). 2. On August 5, 2024, at 11:10 a.m., a concurrent observation and interview were conducted with Resident 36, who was observed lying in bed. Resident 36 stated she felt warm in the room. On August 5, 2024, at 5:16 p.m., a concurrent observation and interview were conducted with the Maintenance Supervisor (MS). The MS checked the temperature in Resident 36's room on the wall above Resident 36's bed using the handheld infrared thermometer gun (a device that measured an object's temperature without making physical contact with it). The temperature read 87.4 degrees Fahrenheit. The MS stated the room temperature in Resident 36's room was not within the required comfortable range of 71 to 81 degrees Fahrenheit. On August 6, 2024, Resident 36's admission RECORD was reviewed. Resident 36 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a common lung disease that causes breathing problems and restricted airflow) hypertension (high blood pressure), and dementia (loss of cognitive function, memory and thinking). A review of Resident 36's MDS, dated July 16, 2024, indicated a BIMS score of 3 (severe cognitive impairment). 3. On August 5, 2024, at 11:18 a.m., a concurrent observation and interview was conducted with Resident 28. Resident 28 was observed lying in bed, receiving oxygen via nasal canula (a device that delivers extra oxygen through a tube and into your nose) which was connected to an oxygen concentrator [a machine which delivers supplemental oxygen]. The oxygen concentrator had cluttered personal items on top of it. A floor fan was observed blowing directly on Resident 28's face. In a concurrent interview, Resident 28 stated it was hot in the room and she had informed the nursing staff, the MS, and the maintenance assistant about the heat, but nothing was done. Resident 28 stated the heat problem in the room had been over a month. Resident 28 stated the facility provided a cooler outside her door, but they were so noisy, especially with the television on. On August 5, 2024, at 11:35 a.m., a concurrent observation and interview were conducted with the MS. The MS was observed to use a portable infrared handheld thermometer gun to check the temperature in Resident 28's room. The MS checked the temperature in the following areas of Resident 28's room with the following readings: - On the wall above Resident 28's head: 83.7 degrees Fahrenheit; - Above Resident 28's bed (at the level of bed light): 82.9 degrees Fahrenheit; and - The wall by the bathroom: 82.4 degrees Fahrenheit. During further interview with the MS, the MS stated the temperature should be between 65 to 85 degrees Fahrenheit. On August 5,2024, at 2:31 p.m., a concurrent observation and interview were conducted with the MS. The clock thermometer in Resident 28's room showed a reading of 85 degrees Fahrenheit, while Resident 28's personal room thermometer showed a reading of 84.4 degrees Fahrenheit. The MS was observed checking the temperature by the head of Resident 28's bed using a thermometer gun, which showed a reading of 87.7 degrees Fahrenheit. On August 5, 2024, Resident 28's admission RECORD was reviewed. Resident 28 was admitted to the facility on [DATE], with diagnoses which included asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe) and chronic respiratory failure (long-term condition that occurs when the body's respiratory system cannot exchange oxygen and carbon dioxide properly). A review of Resident 28's MDS, dated July 16, 2024, indicated a BIMS score of 12 (cognitively intact). 4. On August 5, 2024, at 11:20 a.m., Resident 15 was observed lying in bed. Resident 15 was not able to answer questions appropriately when asked about the heat inside her room. On August 5, 2024, Resident 15's admission RECORD was reviewed. Resident 15 was admitted on [DATE], with diagnoses which included Alzheimer's disease (progressive disease that destroys the memory), and hypertension. A review of Residents 15's MDS, dated June 12, 2024, indicated a BIMS score of 3 (severe cognitive impairment). On August 5, 2024, at 2:42 p.m., the Administrator (ADM) was interviewed. The ADM stated he was initially made aware the air conditioning (AC) was broken around the first week of July 2024. The ADM stated the facility received a recommendation order for AC units 4 and 5 and obtained price quotes on July 10, 2024 and August 2, 2024. The ADM stated the facility acquired portable cooler fans and placed them in the hallway near the back hall station. The ADM stated the facility was not achieving the appropriate temperature level for resident's comfort. The ADM stated the MS checked the facility temperature daily and the facility's policy indicated the room temperature should be between 68 and 85 degrees Fahrenheit. The ADM stated he felt the humidity in Resident 28's room and found it uncomfortable. On August 5, 2024, at 4:45 p.m., the MS was interviewed. The MS stated two AC units had broken sometime in July 2024. The MS stated these broken AC units affected the rooms of Residents 15, 40, 36, 17, 32, 53, and 48. The MS stated they called an AC professional who recommended replacing the two broken AC units. The MS stated he received several price quotes for the AC units in July 2024, and submitted to the ADM. The MS stated the two broken AC units had not yet been replaced as of this time. The MS stated they have placed portable AC units in the hallways outside the affected residents' rooms. The MS stated the portable AC units were not sufficient to provide cooler air in the residents' rooms. The MS stated the required room temperature should be 71 to 81 degrees Fahrenheit. On August 5, 2024, at 4:47 p.m., a concurrent interview and review of room temperature monitoring log from July 2024 to August 2024, were conducted with the MS. The MS stated room temperatures were checked twice a day by him, and two other maintenance staff members. The MS stated, the temperature monitoring log did not indicate any temperature readings below 71 degrees Fahrenheit or above 81 degrees Fahrenheit. The MS stated the facility did not have a policy and procedure on how to accurately check a resident's room temperature using the infrared thermometer gun.