F0584

E

Unaddressed Ceiling and Wall Leaks Created Non-Homelike Resident Environment

San Diego, California Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment by not identifying and repairing leaking ceilings and walls in multiple resident rooms on the fourth floor. During a facility tour on 1/2/26, the Director of Maintenance (DOM) reported that the only leak he had been informed of was in the third-floor dining room and that it had been addressed by resealing a sliding glass door. However, observations and resident interviews revealed that rooms 417, 421, and 425 had experienced significant water intrusion during recent rain, with visible water damage to ceilings and walls and reports of flooded bathrooms and floors. The DOM stated he was not aware of the damage in these areas.

Resident 3, who had a history including right femur fracture, fall, atrial fibrillation, and chronic kidney disease and a BIMS score of 11 (moderate cognitive impairment), reported that her bathroom floor had been very wet the previous night and that staff had to place many towels to absorb the water. Observation of her bathroom showed water damage on the ceiling with wet spots and towels on the floor, and she stated that the flooding and water damage were not homelike. Resident 4, with diagnoses including neuropathy, rheumatoid arthritis, and fibromyalgia and a BIMS score of 12 (moderate cognitive impairment), similarly reported that her bathroom had flooded the previous night and that staff had placed many towels to soak up the water. Her bathroom showed water damage and bubbling paint on the ceiling, and she stated that the water on the floor was dangerous and not homelike.

Resident 5, with acute kidney failure, rheumatoid arthritis, and depression and a BIMS score of 15 (intact cognition), reported that her roommate’s wall had leaked a lot the previous night and that staff had put down many towels to absorb the water; she stated that the leaking wall was not homelike and could have been dangerous if someone slipped. Resident 16, with a history of fall, COPD, and CHF and a BIMS score of 11 (moderate cognitive impairment), reported that there had been a lot of water on the bathroom floor the previous week, that staff had placed big towels from the wall to the toilet to the door, and that no one could use the bathroom; she stated that the leaking ceilings and flood were not homelike. Staff interviews (RNs and CNAs) consistently described their immediate response to leaks as moving residents if needed, placing towels to control water, and contacting maintenance by phone or Teams and documenting in a maintenance binder, and they all acknowledged that leaking ceilings, flooded bathrooms, and water-damaged walls were not homelike and could present slipping hazards.

Review of the fourth-floor maintenance binder on 1/2/26 and 1/9/26 showed no entries documenting the leaks or repairs for rooms 417, 421, or 425, despite staff and resident reports of flooding and water damage. The DOM and a maintenance worker stated that staff were expected to report leaks via phone or Teams and to document them in the maintenance binder, and that repairs should also be documented there so that completion could be tracked. Both the DOM and the Administrator acknowledged that leaking ceilings and water-damaged walls were not homelike and that the facility should be aware of and immediately repair such issues. The facility’s “Homelike Environment” policy stated that residents are to be provided with a safe, clean, homelike environment, including a clean, sanitary, and orderly environment, which was not maintained in the affected rooms due to the unaddressed leaks and resulting water damage.