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F0584
D

Failure to Maintain Safe and Homelike Resident Environment

Bell Gardens, 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, clean, and homelike environment for two residents. In one instance, a resident's bathroom wall had black and red spots, and the bathroom door panel was damaged. The resident reported that the maintenance supervisor had been notified about the broken door two weeks prior, but no repairs had been made. The resident stated that the broken door panel posed a safety risk, as it had previously caused injury to his foot. Housekeeping staff confirmed the door had been broken for several weeks and that the issue was not documented in the maintenance repair book. The housekeeping supervisor acknowledged the risk of injury and stated that it was the facility's responsibility to ensure resident safety. In another instance, a resident's toilet seat cover was observed to be broken in half. The maintenance supervisor agreed that the toilet seat should have been fixed to maintain a safe and homelike environment. Housekeeping staff observed the broken toilet seat the previous day but did not document it in the maintenance book or inform the maintenance supervisor. The certified nursing assistant stated that a broken toilet placed the resident at risk for skin injuries and falls. The director of nursing confirmed that the facility must keep bathrooms, doors, toilet seats, and walls in good condition to provide a safe environment. Facility policies reviewed indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards.

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