Santa Monica Rehabilitation Center

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

concurrent observation and interview on 9/11/2025 at 10:11a.m. with the regional administrator (RA), MS and MA. Inside of a storage closet in the garage stacks of sealed boxes containing portable ac units were observed. The RA stated, A few months back there was an issue with the temperature, and it was hot outside, so I ordered 55 portable ac units for the building, and they have been here. The MS and MA both stated, yes, we knew they were here. The MA and MS stated they did not offer any of the portable ac units to any of the residents that complained about the hot temperatures at night. Both the MS and MA stated

they did not inform RA nor acting Administrator of the thermostats not working. The RA stated, no one told me the thermostats were not working. Lastly, The RA stated, The HVAC system should be serviced at least quarterly and when there is an issue. During an observation on 9/11/2025 at 1:39pm inside Resident 1 and 2's room there was no portable AC unit. During an observation on 9/11/2025 at 1:48 p.m. inside Resident 3's room there was no portable AC unit. A review of the facility's policy and procedures titled, Maintenance of Building Temperatures/Provisions for Extreme Hot or Cold, revised 9/15/2025 indicated:1i. Required Temperature Range- The building temperature in all resident areas at the facility will be maintained between seventy-one degrees Fahrenheit and eighty-one degrees Fahrenheit.2i. Adjustment and Monitoring of Building Temperatures-Maintenance department staff are responsible for adjusting temperature thermostats and servicing heating and cooling units during the change of seasons. Resident rooms contain separate heating and cooling systems. Those residents who are capable of controlling them may maintain the temperature of their rooms at any level they desire. However, in instances when a resident's desired temperature level adversely affects or has potential for adversely affecting the health and safety of the resident or the health, safety and comfort of any other resident sharing the resident room, the facility will take appropriate intervention. Building temperatures and resident control levels will be monitored by:a. Monitoring thermostats in resident rooms, especially during seasonal changes or periods of extreme outside temperatures.b. Forwarding all complaints or concerns of resident discomfort from building temperatures to maintenance, nursing and administration.3i. Evaluation of Building Temperatures-All reports of temperature problems must be reported to the Administrator or DON. In conjunction with maintenance staff, Administrator and nursing will assess and determine the extent and length of the problem and determine what types of action will need to be taken to ensure health and safety of residents is not jeopardized. The range of possible steps are listed below.Building Systems Service and RepairsPreventive maintenance schedules are maintained on all facility air-conditioner units and the heating system. The facility Maintenance Director and Administrator must be notified whenever there is a malfunction or failure with any of the building's electrical, heating, ventilation or air-conditioning units. 9 Documentation-Any incident or occurrence regarding building temperature that requires implementation of any part of this policy will be documented by the Maintenance Director and submitted to the Administrator within 24 hours after the completion of the occurrence. This record shall be maintained at the facility with

the Administrator for the current calendar year and the preceding calendar year

Event ID:

Facility ID:

If continuation sheet