Health inspection·January 7, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the physical environment was maintained in a safe and well-kept condition by not addressing a ceiling leak during rainy weather.These deficient practices placed 4 out of 8 sampled residents (Resident 1, 2, 5, and 6) and eleven residents who used the physical therapy room at risk for exposure to safety hazards and potential health risks related to unresolved ceiling leaks.Findings:On 1/6/26 at 1:19 P.M., an interview was conducted with the Maintenance Director (MNTD). The MNTD stated roofing contractors visited the facility on Friday (1/2/26) due to the heavy rain which had occurred on 12/26/25. The MNTD stated the roofing contractors did a walk-through but not all areas and rooms at the facility had been checked.On 1/6/26 at 1:21 P.M., an interview was conducted with the Roof Contractor (RC). The RC stated they found some fissures (also known as cracks that are openings in your roof or ceiling from age/weather, water damage, or structural shift) on the membrane (a continuous, watertight layer installed on flat or low-slope roofs to create a waterproof barrier, preventing leaks and protecting the building's structure) of the facility roof as well as roof penetrations (any hole that is made through the roof). The RC stated they did not do a thorough walk-through and only inspected two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) of the building. RC stated that the roof fissures could lead to leaks.On 1/6/25 at 1:30 P.M., a joint observation of room [ROOM NUMBER] and interviews with Resident 1 and Resident 2 was conducted with the MNTD: Resident 1 was observed sitting on his bed watching TV and stated, I noticed leaks on my blankets.Resident 2 was observed lying in bed covered in blankets and stated There was some leaking happening overnight, it was really coming down hard from the last rain (1/5/26) we had. They (staff) placed a bucket on the ground. Resident 2 stated he did inform the staff about the water leak coming through the ceiling and stated staff had brought in buckets to catch the rain and stated it was an unpleasant sight. Resident 2 pointed to the area in the ceiling on the right side of room by the curtain dividers which showed a rippling droop (half-golf ball sized) in the ceiling. The MNTD was then observed testing the ceiling strength of room [ROOM NUMBER] with the end of a broomstick toward the rippling ceiling droop that Resident 2 had identified. The area surrounding the ceiling droop (fist sized) appeared soggy and soft which was easily penetrated by the broomstick end and white debris crumbled off and made a hole the same size as the broomstick end (approximately 1-1.5 inches). The MNTD stated that the droop in the ceiling in room [ROOM NUMBER] indicated rain damage that could result in ceiling collapse on residents and potential health problems from mold. A record review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included history of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing). A record review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of COPD. On 1/6/26 at 2:11 P.M., a Page 1 of 2 555871 555871 01/07/2026 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some joint observation of room [ROOM NUMBER] and interviews with Resident 5 and Resident 6 was conducted with the MNTD: Resident 6 stated there was a leak dripping down from the ceiling at the end of his roommates (Resident 5) foot of the bed by the curtain dividers on the left end of the bed. Resident 6 stated he was concerned for his roommate and was uncomfortable seeing the rain coming down through the ceiling and this could be unsafe if the ceiling collapsed and or we (Resident 5 and Resident 6) could get sick. Resident 6 stated staff had put a bucket under the ceiling leak and staff had stated, they should fix it. Resident 6 stated it was leaking from the heavy rain that happened a few weeks ago.The MNTD was then observed testing the ceiling strength in room [ROOM NUMBER] in the same area where Resident 6 had identified a water leak. The area had a brownish linear discoloration (17.5 inches) with a ripple like drooping ceiling. When MNTD poked the ceiling with the tip of the broomstick a part of the ceiling appeared soggy and soft (approximately 7 inches round).A record review of Resident 5's admission Record indicated Resident 5 was re-admitted to the facility on [DATE] with diagnoses which included a history of Chronic Respiratory Failure with Hypoxia (a decrease in oxygen).A record review of Resident 6's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included a history of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing).On 1/6/26 at 2:24 P.M., the Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated the facility had water leaks in residents' rooms that included room [ROOM NUMBER] (Resident 5 and Resident 6's room) and there were also water leaks in the Physical Therapy (PT) room. CNA 1 stated they (staff) had buckets or trashcans to catch the water that leaked from the ceilings during the rain that happened within the last 1-2 weeks ago. CNA 1 stated staff had told MNTD about it.On 1/7/26 at 3:08 P.M., a joint observation (of the PT room) and interview with the Physical Therapy Assistant (PTA), and Speech Therapist (ST) was conducted with the MNTD. The PTA and ST stated there were water leaks in the physical therapy room which came from the air vent by the charting area and the air filter vent had a black linear line on the bottom right corner. On 1/6/26 at 3:16 P.M., an interview was conducted with MNDT. The MNDT stated the facility had received past complaints from the residents about the water leaks starting around 12/1/25. The MNTD stated he thought he was being proactive but had not contacted the roof contractors until after the rainy days had occurred, within the last 1-2 weeks. The MNTD stated if the roof continued to not be fixed this could cause safety risks and mold concerns. The MNTD stated the roof can cave in and collapse.On 1/6/26 at 4:51 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated there were leaks in rooms 21, 23, 6 or 8 and the Physical therapy room. LN 1 stated the leaks started within 2 weeks of the rainy days. LN 1 stated if the leaks were not fixed it was possible that the ceiling could collapse and hurt residents. LN 1 stated there could be health risks with mold build up and this was not a homelike environment. LN 1 stated we defiantly need to get the roof fixed.A record review of a list of residents who received rehabilitation services was conducted. The Rehab therapy list dated from 12/14/25 to 1/5/26 listed eleven Residents who received rehabilitation services and utilized the physical therapy room. On 1/7/26 at 3:15 P.M., an interview was conducted with the DON. The DON stated, enough is enough we need to fix the roof. The DON stated if left unresolved (leaky ceiling) could lead to safety (falling debris from ceiling and accidents) risks and health concerns with mold that affects all residents. A review of the facility's policy and procedure titled, Physical Environment (undated), indicated .Equipment and environmental conditions needing repair will be logged and acted upon at a reasonable timeframe, as appropriate 555871 Page 2 of 2