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Based on observation, record review, and interview, the facility failed to ensure proper temperature controls in 34 of 34 patient rooms (17 rooms on Unit 6 and 17 rooms on Unit 8).

Findings included:

Record review of facility's Emergency Operations Plan and Response Plan dated 5/30/19, page 28, stated "Provisions are made to maintain temperatures to protect patient health and safety .....These temperature requirements include: heating and air conditioning systems to maintain comfort ...."

In an interview on 7/17/19 at 9:15 AM with CEO Staff#51, he stated that the air conditioning on two units (Unit 6 and Unit 8) broke down on 7/3/19. Fans were immediately placed on the units and portable air conditioning units were brought in two days later.

Observation on 7/17/19 at 9:30 AM of facility's Units 6 and 8 revealed there were thermostats with temperature gages only at the nurse's stations. None were found that monitored the temperatures of patient rooms.

Observation on 7/17/19 at 9:45 AM of the facility's remaining units (Units 4, 5, and 7) had stand-alone heating/air conditioning units in each patient room.

In an interview on 7/17/19 at 9:45 AM with CNO Staff #52, she stated that for Units 4, 5, and 7, because each patient room had their own Heating/Air Conditioning units, if a patient complained about being too hot or cold, the temperature could be adjusted by staff.

In an interview on 7/17/19 at 11:30 AM, Director of Plant Operations (DPO) Staff #56 stated that Units 6 and 8 had central air conditioning, which failed on Wednesday 7/3/19 and was fixed on Wednesday 7/10/19. He added that for two days, 7/3/19 and 7/4/19, only fans were used to help cool the units. Afterwards, portable air conditioning units were brought in; two portable units for both Unit 6 and Unit 8.

Further interview with staff #56 revealed that there were four 'circuits' of the central air conditioning for Units 6 & 8, and three circuits broke down, leaving only one working circuit on 7/3/19 and 7/4/19. This one circuit, in combination with the fans placed, he stated, helped keep the units cool. The air conditioning did not completely fail.

When asked if he checked the temperatures of the patient rooms, DPO Staff #56 stated he did visual checks of the thermostats located at the nurse's station but did not document it. He also stated that the temperatures in patients' rooms were not monitored or documented.

In an interview on 7/17/19 at 11:40 AM with Director of Performance Improvement Staff #53, he stated that temperatures of each unit was documented every day on Temperature Logs.

Record review at time of survey of temperature logs for Units 6 & 8 revealed the following: it was not specific for measuring the temperatures in any specific patient rooms and the form only stated "Room". Acceptable ranges were from 68 F to 77 F. From 78 F to 85 F, it stated "OUT OF RANGE-TAKE ACTION IMMEDIATELY (Call House Supervisor)". For temperatures of 67 F to 60 F, it stated "OUT OF RANGE-TAKE ACTION IMMEDIATELY (Call House Supervisor)". It was later determined this form was for use in the medication rooms.

Review of Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules, 133.169(c), Table 3; Ventilation Requirements for Hospitals and Outpatient Facilities, under Nursing: "Patient room ...Design temperature (degrees F) ....70-75 (degrees Fahrenheit).