**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the facility cooling system to provide eight of 12 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8) an environment with a safe and comfortable temperature. The failure to prevent excessive heat (temperatures in excess of 81ºF, degrees Fahrenheit) in the facility resulted in physical discomfort for Residents 3, 4, 6, 7; Resident 5 was nauseous for three days; Resident 2 had difficulty sleeping; and Resident 1 was unable to receive restorative nursing care for two days. This failure had the potential for dependent, bed-bound Residents 1, 2, 3, 5 and 6 to suffer death or disability as a result of heat stroke (the body temperature rises rapidly, sweating mechanisms fail, and the body is unable to cool down) and/or heat exhaustion (the body overheats causing excessive sweating and rapid pulse). This failure resulted in an Immediate Jeopardy (IJ, a situation in which a facility's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). The facility's Director of Nursing (DON) was notified of the IJ on 8/17/23, at 5:46 p.m. The facility submitted an acceptable Plan of Action to prevent excessive heat in the facility on 8/22/23, at 12:05 p.m., and based on observation, staff and resident interviews, and record reviews, the IJ was lifted during an onsite visit on 8/23/23 at 3:34 p.m. Findings: During a review of an email dated 8/24/23, at 11:32 a.m., written by the ombudsman (OBM), the email indicated the ombudsman had been visiting residents at the facility on 8/15/23, from 2:30 p.m. to 3:00 p.m. The email indicated the OBM noted the therapy room had several residents in the therapy room and the wall thermometer showed a temperature of 82ºF. The email indicated the OBM observed thewall thermometer in the occupational therapy room showed a temperature of 92ºF; there were no residents in the occupational therapy room at that time. During a review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility in 2017 with diagnoses of quadriplegia (a form of paralysis that affects all four limbs, plus the torso) and left and right ankle contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints and decreased mobility and function). During a record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/28/23, the MDS indicated Resident 1 used a wheelchair for mobility, required extensive assistance from one person for bed mobility, and total assistance from two people for transfer between surfaces. The MDS indicated Resident 1 had a score of nine on the Brief Interview for Mental Status exam. (BIMS, a tool to determine a resident's cognitive ability to remember and recall information; a score of 8-12 indicates moderately impaired cognition.) During a concurrent interview and record review, on 8/21/23, at 12:40 p.m., with the DON, Resident 1's care plan titled, Restorative Nursing Program: Splint/Brace Assistance, dated 3/2/23, and Treatment Record dated 8/12/23 to 8/20/23, was reviewed. The DON stated Resident 1's care plan indicated for two hours per day, five days per week, Resident 1 should have splints applied to both ankles/feet and both hands/fingers. The DON stated the Treatment Record indicated Resident 1 had refused the ankle/foot and hand/finger splints on 8/16/23 and 8/17/23; the Treatment Record did not indicate the reason for the splint refusal. During a concurrent observation and interview on 8/17/23, at 3:20 p.m., with the OMB and Maintenance Supervisor (MS), in Resident 1's room, Resident 1 sat in a wheelchair next to his bed under the air conditioning (A/C) vent. MS stated Resident 1's room had functional air conditioning, and no portable A/C unit was necessary to maintain adequate cooling. MS stated the air vent directly above Resident 1 was for cool air entry from the A/C unit in the attic and used an infrared surface thermometer (device that uses infrared light to measure surface temperature) to obtain a temperature of 69ºF at the surface of the vent outlet. During a concurrent observation and interview, on 8/17/23, at 3:25 p.m., in Resident 1's room, with Resident 1, and OBM and MS, Resident 1 was in a wheelchair in his room next to his bed with a bedside table in front of him. Resident 1's forehead and neck were glistening with sweat. Resident 1 stated he was a quadriplegic and was unable to reposition himself for comfort or for cooling. Resident 1 stated he was uncomfortable because there was no cool air in the room and the room was getting hot. Resident 1 stated he had contractures of his limbs and needed to wear splints on his hands and feet, but the past few days were so hot, and the portable A/C had been taken out of his room a few days ago, so he could not tolerate wearing the splints. A clinical digital thermometer (CDT) was placed on Resident 1's bedside table with the probe tip left in free air and allowed to equilibrate for 6 minutes: the CDT indicated the air temperature was 84.9ºF. During a review of Resident 2's admission record, the record indicated an admission date of 7/22/23 for aftercare following knee replacement surgery. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had a BIMS of 14 (an indication of intact cognitive status). The MDS indicated Resident 2 required a wheelchair and extensive assistance from one person for locomotion between rooms. The MDS indicated Resident 2 had received physical therapy five days out of the seven day look back period. During a concurrent observation and interview, on 8/17/23, at 4:12 p.m., with Resident 2, Resident 2 sat in a wheelchair in the rehabilitation therapy room. The wall thermostat (device which measures room temperature and adjusts the function of the A/C based on the temperature) indicated the rehabilitation therapy room temperature was 86ºF. A second temperature reading taken with a CDT with the probe tip left in free air and allowed to equilibrate for 5 minutes indicated an air temperature of 86ºF. The rehabilitation therapy room had two portable A/C units operating in the room. Resident 2 stated the temperature and comfort of the facility was a joke. Resident 2 stated he had been here a month and his room was always hot and uncomfortable. Resident 2 stated his room got so hot this week he had difficulty sleeping at night. Resident 2 stated when he complained to staff about the heat, he had received one [expletive] popsicle and a warm drink to help him cool down. Resident 2 became visibly upset and started pointing and shaking his finger. Resident 2 stated he was here for rehabilitation after knee surgery, but the rehabilitation therapy room was too hot for therapy. Resident 2 stated he had complained about the rehabilitation room temperature, but nothing was done to correct it. Resident 2 stated he did his physical therapy in the front hallway with other residents because the therapy room was so hot. Resident 2 stated the facility knew they needed to fix the A/C, but they refused and allowed residents to suffer. During an interview, on 8/17/23, at 4:05 p.m., with rehabilitation staff (RS), RS indicated the rehabilitation therapy room was too hot for residents to safely complete rehabilitation despite the portable A/C units and fans in the room. RS stated the rehabilitation equipment had been moved into the hallway for residents to complete their therapy. RS stated the rehabilitation room A/C was not functional. During a review of Resident 3's admission record, the record indicated Resident 3 was admitted to the facility in 2022 with a diagnosis of chronic (long-term) difficulty in breathing. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 required extensive assistance from one person to reposition herself in bed. The MDS indicated Resident 3 required a wheelchair and was totally dependent on one person for locomotion. The MDS indicated Resident 3 had a BIMS score of 13 (an indication of intact cognitive status). During a concurrent interview and observation, on 8/17/23, at 3:53 p.m., with Resident 3, in her room, Resident 3 lay in bed with no covers on. Resident 3's bed was next to an open window; outside air was blowing through the window into the room. There was no portable A/C unit in the room. Resident 3 stated the room was hot right now but had been hotter the past few days. Resident 3 stated for the past few days she was melting from the heat because her room did not have A/C. Resident 3 stated staff gave her popsicles, but the relief was temporary and not enough to keep her comfortable and cool. The CDT was placed at the foot of Resident 3's bed in free air and allowed to equilibrate for 3 minutes and indicated a temperature of 88.2ºF. A second temperature was taken with the CDT placed near the room entrance and indicated a temperature of 88ºF. During a review of Resident 4's admission record, the record indicated Resident 4 was admitted to the facility with diagnoses of depression, high blood pressure, and difficulty breathing. During a concurrent observation and interview, on 8/17/23, at 3:03 p.m., with MS, in Resident 4's room, Resident 4 lay in bed with no covers on. MS stated Resident 4's room was not supplied with cool air from the working A/C units but would be supplied with a portable A/C unit if the room temperature was over 79ºF. During a concurrent interview and observation, on 8/17/23, at 3:46 p.m., with Resident 4, in Resident 4's room, Resident 4 wore a hospital gown and lay in bed on top of the bed covers. Resident 4 stated it was uncomfortably hot in the room, and she was waiting for staff to bring her a popsicle. Resident 4 stated her room has been unbearably hot for the past few days. Resident 4 stated she would never keep her own home at this temperature. The CDT was placed on Resident 4's bedside table exposed to free air and allowed to equilibrate for 3 minutes. The CDT indicated the room was 86.2ºF. The room did not have a portable A/C unit. During a review of Resident 5's admission record, the record indicated Resident 5 was originally admitted in 2015 with diagnoses of quadriplegia, hypothyroidism (a malfunctioning thyroid gland which can cause disruptions of heart rate, and body temperature) and familial dysautonomia (a genetic disease which can cause disruptions in the nervous system and effect body temperature control, blood pressure and digestion). The admission recorded further indicated she was her own responsible party. During a concurrent interview and observation, on 8/18/23, at 12:20 p.m., with Resident 5, Resident 5 sat in a wheelchair in her room next to a window with an air conditioning unit and fan pointed directly toward her. Resident 5 stated she had been in the facility for years and there had never been a summer when the temperatures were comfortable. Resident 5 stated the past week the hallway became so hot and uncomfortable she got nauseous when she went out to the hallway and had to take additional medication to keep from vomiting. Resident 5 stated she took [brand name ondansetron] (a medication for nausea) and [brand name dimenhydrinate] (a medication for nausea). Resident 5 stated she normally doesn't take [brand name dimenhydrinate] but she had to take it a few times this week because the heat was making her nauseous. Resident 5 stated she had brought up the temperature issues during Resident Council numerous times but the facility response was a band-aid fix for the air conditioning units that broke again within a month. During an observation on 8/17/23, at 5:15 p.m., a wall thermometer in Resident 5's room indicated a room temperature of 84ºF. During a review of Resident 5's August medication administration record (MAR), the MAR indicated Resident 5 received dimenhydrinate for nausea on 8/17/23 at 10:37 a.m., 8/16/23 at 12:51 p.m., and on 8/13/23 at 10:12 a.m., and ondansetron for nausea twice a day on 8/12/23, 8/13/23, 8/14/23, 8/15/23 and on 8/17/23. The MAR indicated Resident 5 received ondansetron once on 8/16/23. During a record review of Resident Council Minutes, dated 5/5/23, The minutes indicated resident's rooms need to be checked for temperature regulation and rooms need fans as it gets hotter. During a record review of Resident Council Minutes, dated 6/2/23, the Minutes indicated a current discussion about temperature control in resident rooms and maintenance issues for resident room thermostats and in the Franchesca Room. The Minutes indicated the resident rooms' temperature control and thermostat maintenance issues were also entered under Old Business. During a review of Resident 6's admission record, the record indicated Resident 6 was originally admitted to the facility in 2015 with diagnoses of heart failure (a chronic condition in which the heart does not pump blood as well it should), chronic obstructive pulmonary disease (a long-term condition of breathing difficulty), and diabetes (uncontrolled blood sugar). The record further indicated Resident 6 was self-responsible and able to make health care decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had a BIMS score of 15 (an indication of intact cognitive status). During a concurrent interview and observation, on 8/18/23, at 1:00 p.m., with Resident 6, Resident 6 sat in a wheelchair in her room. Resident 6 stated she had lived here for five years, and her room A/C and heat have never worked right so every summer residents had to suffer through the heat. Resident 6 stated she had breathing problems and diabetes and being hot made those conditions worse. Resident 6 stated on 8/17/23 in the afternoon, she was in the activities room listening to music and felt so hot she thought she was having a heart attack and had to return to her room to recover. During an observation, on 8/17/23, at 4:50 p.m., a wall thermometer in the activities room indicated a temperature of 85ºF. A review of Resident 7's admission record indicated Resident 7 was admitted to the facility with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and hypothyroidism. The admission record indicated Resident 7 was responsible for herself and had capacity to make health care decisions. A review of Resident 7's MDS, dated [DATE], indicated she required assistance from two people for bed mobility and one person's assistance for transfer to a wheelchair. The MDS indicated Resident 7 had a BIMS score of 12 (moderate cognitive impairment). The MDS indicated Resident 7's choice of clothing was very important. A record review of Resident 7's annual physical exam, dated 8/19/22, indicated Resident 7 had capacity to make health care decisions. During a concurrent interview and observation on 8/17/23, at 2:36 p.m., with Resident 7, Resident 7 lay in bed in her room, on top of the bed covers, next to the window. Resident 7 wore a hospital gown. There was a fan in the room circulating room air toward Resident 7. Resident 7 stated her room was always hot, so she was limited to wearing a hospital gown. Resident 7 stated she had complained to staff about the heat in her room, so a portable A/C unit had been brought to her room but had then been removed. Resident 7 stated her room felt like it was 80ºF, and she was only comfortable at 70ºF due to her difficulty in repositioning herself. During an observation on 8/17/23, at 3:33 p.m., the CDT was placed on Resident 7's bedside table and allowed to equilibrate for 5 minutes. The CDT indicated a temperature of 82.2ºF. During a review of Resident 8's admission record, the record indicated Resident 8 was admitted in 2022 with a diagnosis of difficulty breathing, diabetes, and generalized muscle weakness. The record further indicated she was responsible for herself and had capacity to make health care decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated a BIMS score of 15. During a concurrent observation and interview on 8/18/23, at 12:35 p.m., with Resident 8, Resident 8 sat in a wheelchair in the hallway. Resident 8 stated the A/C in her room was working today but had not worked yesterday or in the past week. Resident 8 stated for the past week, her room got so hot she could not stay in her own room but went to her friend's room to stay cool. During a record review of the monthly weather data for the facility's city titled Accuweather Pittsburg, CA, dated 8/2023, the monthly weather data indicated the following high temperature readings: 8/13/23 - 100ºF 8/14/23 - 99ºF 8/15/23 - 104ºF 8/16/23 - 98ºF 8/17/23 - 103ºF 8/18/23 - 93ºF. During a concurrent observation and interview, 8/18/23, at 2:10 p.m., with MS, the facility's A/C units in the attic were inspected. MS stated the attic A/C units were to provide cool air to the resident rooms and other areas of the facility. MS stated the A/C units were dependent on a cooling tower outside the building in order to function correctly. MS stated multiple attic A/C units were partially disassembled or had the electrical wiring disconnected. MS stated he was unable to provide the reason for the disassembled A/C units. MS stated some A/C units could circulate air, but were unable to cool the air, so uncooled attic air would be circulated to resident rooms if staff or residents turned the units on. MS stated on hot days, the attic air could reach over 110ºF. MS stated five A/C units in the attic were currently operating. MS stated the working A/C units pulled fresh air from the attic space, cooled the air, and blew the cool air to resident areas. During a review of the A/C company's repair summary titled Invoice, dated 5/31/23, the invoice indicated the A/C repair company noted the facility had four operable A/C units and 11 A/C units in need of repair. The Invoice summary further indicated the cooling tower was in dire need of service or replacement and showed signs of yearly neglect. During a review of an A/C repair update titled Water Source Heat Pump Research, dated 6/28/23, the document indicated most of the water source heat pumps (technical designation of the A/C units) were not functional or had limited functionality. The update indicated the cooling tower was not operating properly and was in poor condition. During a review of an A/C repair update email titled, Invoice 1072, dated 8/2/23, the document indicated A/C unit #1 was operating at roughly 30% efficiency. The email indicated a replacement compressor would restore 100% efficiency if the cooling tower could function adequately. During a review of an A/C repair update email titled, RE: Summary of 8/11/23 visit, dated 8/17/23, the email indicated the A/C repair company was unable to complete A/C repairs in the facility attic because of the extreme heat in the attic. The update further indicated a solarium A/C unit that was not working because it was completely disassembled and was missing all major components. The email indicated six A/C units covering resident rooms 101-115, 201-207, rehab gym, dining room and solarium were not working. The email further indicated the A/C unit for rooms 117-135 was operating at a reduced efficiency. During an interview on 8/17/23, at 2:50 p.m., with MS, MS stated the facility utilized portable A/C units in resident rooms to maintain a temperature below 81ºF. MS stated not all rooms had portable A/C units because the facility was at or near the capacity of the electrical system. MS stated adding more portable A/C units would trip the circuit breakers (device which prevents electrical fire due to excess electric loads) and cause the power to go off. MS stated he had to prioritize which rooms could get those A/C units based on daily temperatures taken in the morning and the afternoon and whether the room could be cooled from the attic A/C units. During an interview on 8/17/23, at 2:42 p.m., with the DON, the DON stated the resident room A/C units were not functioning so portable A/C units were being used to cool resident rooms. During a concurrent observation and interview on 8/17/23, at 5:44 p.m., with the DON, the hallway next to the DON's office and rehabilitation room had no power: lights and fans in the hallway were observed to be non-functional. The DON stated she was on the phone with MS for instructions on how to reset the electrical breaker so power could be restored. During an observation on 8/17/23, at 5:58 p.m., the hallway next to Resident 12's room showed no working fans in the hallway; the portable A/C unit in Resident 12's room was not working while Resident 12 was in the room; lights and electronic equipment at the nurses' station and the adjacent hallway had no power. During an observation on 8/19/23, at 2:45 p.m., in the hallway next to Resident 12's room, the lights in the hallway turned off and a portable A/C unit in Resident 12's room quit working. A fan in the hallway continued to function. During an interview on 8/21/23, at 12:02 p.m., with MS, Administrator, and the regional management representative, the MS stated the two observed power outages on 8/17/23, at 5:44 p.m. and 8/19/23, at 2:45 p.m., were due to the circuit breakers turning off the power to those circuits due to excess electricity demands from the portable A/C units and patient care equipment. During a review of facility's policy and procedure (P&P) titled, Resident Environmental Quality, dated 12/19/22, the P&P indicated the facility shall maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The P&P further indicated, preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. The P&P further indicated resident rooms and activity areas should be of a comfortable temperature for the resident and resident behavior should be observed to determine appropriate temperature levels. A review of facility's P&P titled, Loss of Heating or Cooling, dated 12/19/22, indicated, It is the policy of this facility to take immediate actions when the facility's heating or cooling systems are inoperable in order to maintain temperatures within the facility at 71-81ºF.