Health inspection·March 7, 2024

42 CFR §483.90 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 2/5/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility reported incident (FRI) about physical environment. The facility failed to provide a safe environment for 95 residents in-house (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, and 95), staff, and visitors, as indicated in its policies and procedures (P&P) by: 1. Not ensuring the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. Not ensuring the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof. 3. Not maintaining the ceiling structure free from moisture, water damage, active leaking, and degradation due to rainwater penetrating through cracks, holes, or other damaged areas of the roof. As a result, on 2/5/2024, during a rainstorm, there were 13 water leaks throughout the facility ceiling requiring Resident 20, 23, and 90 to be displaced and endangering the lives of the 92 residents remaining in the facility by placing them at risk for electrical shocks, electrical fires, and subjecting the residents to possible serious structural damage. A review of a licensed roofing contractor report titled, “Inspection Report 6602,” dated 9/29/2022, indicated the roof assessment findings were as follows: 1. Lifting roof along all edge metal West and South edges 2. Cracked mastic (high-grade construction adhesive) at all flashings (water resistant layers, metals, plastics, or other durable materials installed inside walls during construction) and platform corners 3. Exposed nails at platform 4. Lifting torch repair (when an area of the roof is heated so that the materials adhere to the surface) 5. Exposed nails at top of parapet walls (heavy railing around the edge of a roof) 6. Large low areas at torch repair where water pools 7. Cracks in sheet at low areas 8. Needs new platform where sheet metal was used 9. Loose slash (accumulation of debris) 10. One missing heat stack cap (allow air and fumes to exit the duct freely) eight (8) inches 11. Exposed coping metal over cap sheet at East and West wall 12. Hole and parapet wall 13. Cracked and peeling repair 14. Lifting cap sheet (covers and protects the layers below it, helping to extend the life of the roof) along entire South wall 15. Torn cap sheet at base of Air Conditioning platform During a review of the document titled, “Maintenance Request” dated from 12/16/2022 to 1/2/2023, indicated there was a maintenance request submitted for “a hole in the ceiling 6A – dripping” on 12/31/2022 at 9:00 p.m. On 2/5/2024 at 2:05 p.m., during a concurrent observation and interview, the Maintenance Assistant 1 (MA 1) was checking a water leak from the ceiling lamp inside the lobby. MA 1 stated that a roofing company was called to assess the status of the roof. When MA1 was asked when the last check of the roof was, MA 1 stated the Maintenance Supervisor (MS) was responsible for checking the roof. On 2/5/2024 at 2:10 p.m., during a concurrent observation and interview with the MS, water was leaking from the uncovered ceiling lamp in the lobby into a bucket in the hallway between Rooms 111 and 112. The MS told MA 1 to turn off the light for the affected ceiling lamp in the lobby. The MS stated that the ceiling in the hallway between Rooms 111 and 112 was wet and swelling from the water dripping onto the ceiling. The MS stated he was unable to recall the last time the condition of the roof was checked and that he did not keep any logs for the roof checks. The MS explained he checks the roof monthly or when needed. On 2/5/2024 at 3:13 p.m., during a concurrent observation and interview, the Infection Preventionist (IP) stated that the ceiling seemed to have been previously patched. On 2/5/2024 at 3:13 p.m., during an interview, the Director of Nursing (DON) stated that the ceiling inside Room 116 had started to leak water. The DON stated they would begin to move the residents (Resident 36, Resident 37, and Resident 38) out of Room 116. On 2/5/2024 at 3:15 p.m., during a concurrent observation and interview with the MS and the IP, the IP stated that the water was dripping from the curtain rail inside Room 110 between Bed-B (middle bed) and Bed-C (by the window). A bucket was placed on the floor collecting the water leaking from the ceiling. On 2/5/2024 at 3:18 p.m., an observation of the hallway between the Central Supply (CS) Room and Room 117 with the IP was conducted. There was water leaking from the ceiling lamp and a bucket on the floor collecting rainwater. The IP confirmed the observation. On 2/5/2024 at 3:30 p.m., an observation of the hallway between Rooms 223 and 224 with the IP was conducted. There was water leaking from the ceiling dripping into a bucket placed on the floor. The IP confirmed the active water leak. On 2/5/2024 at 3:35 p.m., during a concurrent observation of the kitchen and an interview with Dietary Aide 1 (DA 1), there were three ongoing water leaks from the ceiling. DA 1 stated the three areas were as follows: a. A rainwater leak in the kitchen’s small storage room. DA 1 stated that water was dripping from the ceiling ventilation and dripping into a bucket placed on the floor. b. A rainwater leak from the ventilation opening near the walk-in refrigerator. DA 1 stated that water was leaking directly onto the floor. DA 1 stated the leak had just started and that he would be placing a bucket on the floor to collect the water. c. A rainwater leak from the ventilation opening near the kitchen’s plate warming station. The water was being collected in a bucket. DA 1 stated this leak had started the previous night (2/4/2024). On 2/5/2024 at 3:47 p.m., during a concurrent observation and interview with the IP and Activity Assistant 1 (AA 1), three areas of water leaking from the ceiling in the Dining/Activity Room were noted. The IP stated one leak was on the left side corner of the ceiling and two leaks at the end of the Dining/Activity room ceiling, opposite side of the door next to the fireplace. AA 1 stated the water leaks had started in the morning (2/5/2024). On 2/5/2024 at 3:50 p.m., during a concurrent observation and interview with the IP, there was a water leak in the facility’s Family Room with a bucket collecting the rainwater. The IP stated there was hole on the ceiling. On 2/5/2024 at 6:51 p.m., during an interview, a Roofing Company Employee (RCE) stated that he was there to look at the roof. The RCE stated that the roof was an old gravel (small stones applied on top of the final coating of asphalt to protect the roof) roof and that they were looking for holes that they would “temporarily fix” them that night. On 2/5/2024 at 6:57 p.m., during an interview, the DON stated Resident 20, Resident 23 and Resident 90 had to be transferred to other skilled nursing facilities (SNF) to protect the residents due to the on-going water leaks in the building. A review of Resident 90’s Physician Order dated 2/5/2024, timed at 6:33 p.m., indicated to temporarily transfer Resident 90 SNF 1 due to environmental hazard. A review of Resident 20’s Physician Order dated 2/5/2024, timed at 6:41 p.m., indicated to temporarily transfer Resident 20 to SNF 1 due to environmental hazard. During a concurrent observation and interview on 2/5/2024 at 7:17 PM with the Administrator in the Family Room, a hole in the ceiling to the left of the television mounted on the wall was observed with an active leak dripping from the open hole. The Administrator stated he was not sure if the ceiling material had fallen by itself or if somebody had taken it down. The Administrator stated that he did not think that it was likely that somebody would have opened a hole in the ceiling purposefully. On 2/5/2024 at 8:05 p.m., during a concurrent observation and interview with the Administrator in the hallway outside of Room 111, evidence of a previous patch work repair job was noted on the ceiling where there was an active rainwater leak dripping from the center of the patched area of the ceiling. The Administrator stated the ceiling appeared to have had previous patchwork done in the area where the leak was occurring. On 2/5/2024 at 8:10 p.m., during a concurrent observation and interview with the Administrator in the hallway outside of the Central Supply Closet, evidence of a previous patchwork along with discoloration was observed on the ceiling. A water leak dripping from the center of the old patchworked area was observed to be actively dripping. Pieces from the ceiling had fallen on to the floor below where the active leak was dripping into a trash can. The Administrator stated that the patchwork on the ceiling appeared to be a repair work previously done. On 2/5/2024 at 8:30 p.m., an interview with the IP and a concurrent review of the list of residents able to walk was conducted. The IP stated that there were eight residents able to walk (Resident 9, 11, 20, 26, 27, 73, 80, and 84) and 14 residents wheelchair bound (Resident 8, 10, 12, 15, 16, 18, 24, 35, 58, 62, 65, 72, 83, and 87). The IP stated that these residents had an increased safety risk while walking or moving around in the hallways which could lead to falls or injuries form debris from the ceiling. On 2/6/2024 at 1:34 p.m., during an interview, the Director of Environmental Services (DES) stated that the roof had been temporarily repaired the previous night (2/5/2024). On 2/6/2024 at 3:03 p.m., during a concurrent observation in the kitchen and interview with the Dietary Supervisor (DS), there was water around the ventilation opening actively leaking into a bucket placed on the floor. The DS stated that the leak above the ventilation opening by the plate warming station was still ongoing. On 2/6/2024 at 3:22 p.m., during a concurrent observation of the Family Room and interview with the Administrator in Training (AIT), the previously observed hole in the ceiling, to the left of the television mounted on the wall, appeared to have increased in size. The hole measured at 11 inches at its widest point by six (6) inches at its narrowest point. An active water leak was dripping from the open hole. Pieces of drywall were observed on the floor, beneath the active leak. After measuring the hole, the AIT stated the material on the floor appeared to be from the ceiling above and confirmed there was still an active water leak ongoing. During a concurrent observation and interview with the IP on 2/6/2024 at 3:23 p.m., two newly identified areas affected by water leaks were noted, one leak in the ceiling near Room 220, and a second leak near Therapy Room 2. IP confirmed there were two newly identified ceiling water leaks. On 2/6/2024 at 3:31 p.m., during a concurrent observation in the Dining/Activity Room and interview with the IP and the AIT, a crack with an old patch job was observed by the doors closest to the kitchen. The AIT measured the crack to be one inch long. The AIT stated that water had been leaking from this area the day before (2/6/2024). There was also a brown discoloration around a crack on the ceiling in the middle of an old patch job by the fireplace with an active water leak pouring from the area. The AIT measured the crack to be 22 inches long and the brown discoloration was seven inches in diameter. The AIT stated the ceiling area appeared to have an old patch job and that there was an active leak coming from the crack. During a concurrent observation and interview on 2/6/2024 at 3:44 p.m., with the AIT in the Kitchen, an active water leak was observed dripping from the ventilation in the kitchen ceiling, to the left of the ventilation hood. The AIT stated that there was an active water leak coming from the ventilation. During a concurrent observation and interview on 2/6/2024 at 3:58 p.m., in the hallway by Room 223, a crack and discoloration was observed in the ceiling with an active water leak dripping from the area. A piece of ceiling material, measured to be 17 by 20 inches by the AIT was observed to be missing from the ceiling around the leaking area. The AIT stated that there was a piece of the ceiling that had fallen and stated that there was an active leak. During a concurrent observation and interview on 2/6/2024 at 4:03 p.m., with the AIT in the hallway by Central Supply Room, a discolored and damp area measuring nine (9) inches by nine (9) inches was observed on the ceiling with an active leak dripping from a light fixture. The AIT stated that the discolored area on the ceiling was damp by touching it with his hand and stated that there was an active leak dripping from the light fixture. During a concurrent observation and interview on 2/6/2024 at 4:04 p.m., with the AIT in the hallway outside of Room 220, a damp discolored area was observed on the ceiling. The AIT stated the area was damp after checking it with his hand and measured the discolored area to be 1.5 inches by two (2) inches. During a concurrent observation and interview on 2/6/2024 at 4:11 p.m., with the AIT inside of Room 116, an active leak was observed dripping from a crack over the television mounted on the wall. The AIT measured the crack to be 10 inches long and stated that the crack was in an area where there was a previous patch job. Discoloration on the ceiling was observed and the AIT stated that the area of the discoloration was at the previous patch job. During a concurrent observation and interview on 2/6/2024 at 4:16 p.m., with the AIT inside of Room 110, an active water leak from a hole was observed dripping into a trash can on Bed B. The AIT measured the hole to be ¼ inch in diameter and stated that it was actively leaking. A second water leak dripping from the ceiling was observed to be dripping onto the mattress of Bed B. The AIT stated the dripping from the ceiling was an active water leak. A third water leak was observed to be dripping from the bed curtain rails next to Bed B. The AIT stated that the water was dripping from the bed rail from an active water leak. During a concurrent observation and interview on 2/6/2024 at 4:20 p.m., with the AIT in the hallway by Room 111, a damp, discolored area was observed along a cracked ceiling in the hallway. The AIT stated that the discolored area was damp by checking it with his hand and measured the missing ceiling piece to be 20 by 9.5 inches. During a concurrent observation and interview on 2/7/2024 at 8:38 p.m., with the Construction Manager, inside Room 110, observed water draining from the ceiling in the middle of the room over Bed B. When the Construction Manager made a hole to the ceiling from where the water was draining, observed water drain out from the ceiling hole totaling 3400 milliliters (mL-unit of measure) once measured. During a concurrent observation and interview on 2/7/2024 at 12:30 p.m., with the facility’s Inspector on Record (IOR) in the Dining/Activity Room, moisture was observed on the wooden joists (structure to provide support to the building) inside of the ceiling space visible through an open hole in the ceiling. The IOR stated that the moisture had likely penetrated through the roof and leaked into the space between the roof and ceiling from the rain. During an interview on 2/7/2024 at 4:21 p.m., with the Administrator, a second request for written evidence of communication to CDPH on the re-roofing progress, t