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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555871 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)