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F0921
E

Failure to Maintain Safe and Sanitary Environment Due to Unaddressed Water Leaks

Arcadia, 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 maintain the physical environment in a safe and sanitary condition by not preventing or promptly addressing water leaks in the ceiling of a hallway and a resident's room. Observations revealed a large hole with visible water damage in the ceiling of the hallway in front of the oxygen room, with water leaking into a bin and towels placed on the floor to absorb excess water. Staff interviews confirmed that the water leakage began during a period of rain, and maintenance staff were either unavailable or only began repairs after the issue had persisted for several days. The facility's policy required maintenance to be provided to all areas and for the environment to be kept in good repair, but these standards were not met during the incident. In a resident's room, grayish discoloration and watermarks were observed on the ceiling and wall, and the resident reported that water had leaked from the ceiling the previous night, soaking personal items. The resident, who had significant medical needs including congestive heart failure, chronic respiratory failure with hypoxia, and generalized muscle weakness, was at risk of being directly affected by the leak. Staff confirmed the presence of water damage and acknowledged that the resident could get wet and might not be able to sleep due to the leak. The maintenance assistant was unaware of the issue until it was pointed out during the survey, and there was no documentation of the leak in the maintenance log or the facility's electronic reporting system. Further review of facility policies indicated that maintenance requests should be logged and prioritized, with work orders picked up daily from the nurses' station. However, staff interviews and record reviews revealed that the required reporting and communication procedures were not followed, as no maintenance requests were filed for the leaks, and the maintenance assistant did not check the log as required. The lack of timely reporting and response contributed to the ongoing unsafe and unsanitary conditions in both the hallway and the resident's room.

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