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F0584
D

Failure to Timely Repair Broken Window Compromises Resident Comfort and Safety

Pico Rivera, California Survey Completed on 11-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe and homelike environment for a resident by not replacing a broken window in the resident's room in a timely manner. Observation revealed that the window was covered with a wooden panel, leaving a gap through which cold air entered the room. The maintenance supervisor confirmed that the window had been broken for four days and that the replacement frame was ready to be installed on the day it broke, but the installation was not completed. The maintenance assistant stated that the repair was delayed due to being occupied with other tasks, despite maintenance staff being available on weekends for emergencies. Both the maintenance supervisor and assistant acknowledged that the window should have been repaired promptly to maintain the resident's comfort and safety. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, atrial fibrillation, and schizoaffective disorder, and was dependent on staff for activities of daily living. The resident also had severe cognitive impairment and was unable to make medical decisions. Facility policy required the maintenance department to keep the building in good repair and provide a safe, comfortable, and homelike environment. Interviews with the Director of Nursing and review of facility policies confirmed that the window repair should have been prioritized to ensure the resident's well-being.

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