Inadequate Bathroom Ventilation in Three Rooms
Summary
The facility failed to ensure proper bathroom ventilation in three rooms, as required by licensure reference number 175NAC 12-007.04(D). During observations conducted on August 22, 2024, it was noted that the ventilation systems in the bathrooms of three specific rooms were unable to pull up a single ply of tissue, indicating inadequate ventilation. This deficiency was confirmed through an interview with the Maintenance Manager, who acknowledged that the ventilation systems in these rooms were not functioning correctly and should have been able to perform the tissue test successfully.
Penalty
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Surveyors found that bathroom exhaust vents in two resident rooms were not functioning, as they did not pull air in, despite facility logs indicating that one of these rooms’ vents had previously been checked and recorded as working. Review of the exhaust fan inspection log showed that only a small number of rooms in each hall were checked monthly over several months, and during an on-site observation and interview, the MD confirmed that the vents in the identified rooms were not operating.
Surveyors found that bathroom ventilation systems were not functioning properly in 12 of 27 occupied resident rooms when vents in those bathrooms failed to draw a 1‑ply piece of toilet paper to the vent surface during testing with the MD and Administrator. Facility records showed that monthly exhaust fan checks had been documented as completed, but the log did not identify which rooms were tested or how many rooms were actually checked, and the last recorded check lacked room-specific detail despite multiple rooms having inadequate ventilation.
Surveyors found that the memory care unit had persistent strong mildew and urine odors throughout the hallway, particularly near a resident room, with damp, musty air noted during the entire survey. The Director of Maintenance reported that some incontinent residents urinate on the carpets, which are cleaned with carpet extractors, but the rugs are difficult to dry in winter because windows are not opened and the HVAC is not run as frequently to avoid making it too cold for residents. He confirmed that the dampness and odors have been an ongoing problem and acknowledged that he does not maintain a log of ventilation system use, demonstrating a failure to ensure adequate mechanical ventilation and odor control on the unit.
The facility did not maintain a functioning exhaust system in the indoor smoke room, resulting in cigarette smoke and odor spreading into hallways and dining areas. Multiple staff and residents reported strong smoke odors and visible smoke outside the smoke room, and ventilation fans were found to be either turned off or not working due to power issues.
Surveyors found that ventilation systems in the bathrooms of four resident rooms were not functioning, as evidenced by a lack of airflow during testing with toilet paper. The Maintenance Supervisor confirmed the issue and stated that no routine checks of the ventilation systems had been performed.
Staff failed to promptly report and address a non-operational air conditioning unit in the CCDI unit, resulting in excessive heat and humidity, condensation, and wet floors. Multiple staff observed and attempted to manage the situation without notifying management or maintenance, leading to unsafe conditions for residents until the issue was escalated and addressed.
Nonfunctioning Bathroom Exhaust Vents in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of adequate outside ventilation in resident bathrooms, as required by licensure regulation 175 NAC 12-007.04(D). Review of the facility’s “Exhaust Fan Annual Inspection Log For All Resident Room Restrooms Throughout Facility” dated from 10/15/2025 through 2/10/2026 showed that only three rooms per month were checked in various halls, and that one of the affected rooms in the 300 hall had been checked in December and logged as working. However, during observation on 03/02/2026 at 1:00 PM, the bathroom exhaust vents in two sampled rooms (one in the 300 hall and room 325) were found not to be functioning, as they did not pull air in. In a subsequent observation and interview on 03/03/2025 at 12:25 PM, the Maintenance Director confirmed that the bathroom vents in these rooms were not functioning and were not pulling air in. No information was provided in the report about the medical conditions or histories of the residents occupying the affected rooms at the time of the deficiency.
Failure to Maintain Operational Bathroom Ventilation Systems in Multiple Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident bathroom ventilation systems were operational as required by licensure regulation 175 NAC 12-007.04D. Facility documentation titled “Exhaust Fans” dated as completed on 1/28/26 instructed staff to check all exhaust fans in bathrooms and other specified areas and to verify that airflow was sufficient to hold a piece of paper to the vent when operating. However, during an observation conducted with the Maintenance Director (MD) and the Administrator, the ventilation systems in resident bathrooms in rooms 1, 5, 10, 11, 15, 16, 17, and 18 on the East hall and rooms 1, 2, 3, and 4 on the South hall did not draw a 1‑ply square of toilet paper to the surface of the ventilation cover, indicating that the systems were not working properly at that time. During interview, the MD confirmed that the ventilation systems in these 12 resident bathrooms were not functioning properly, as evidenced by the failure to draw the toilet paper to the vent surface. The MD also confirmed that monthly checks of the ventilation system had been marked as completed in the electronic Exhaust Fan documentation on 1/28/26, but there was no record specifying which rooms had been tested or how many rooms had been completed. The MD acknowledged that the last documented check of the ventilation systems was on 1/28/26 and that the documentation did not identify the specific rooms where exhaust fans had been checked. The facility census at the time was 33, and 12 of 27 occupied resident rooms were found to have non-functioning or insufficient bathroom ventilation.
Inadequate Ventilation Leading to Persistent Mildew and Urine Odors on Memory Care Unit
Penalty
Summary
Surveyors identified a deficiency related to inadequate mechanical ventilation on the licensed memory care unit (B‑Wing), where a strong odor of mildew was noted upon entering the unit and a combined mildew and urine odor was present down the entire hall near a specific resident room. The damp, musty, and urine smells persisted throughout the survey period. During an interview and walkthrough with the Director of Maintenance, he explained that some incontinent residents urinate on the carpet in various locations, and staff use carpet extractors to clean the rugs, attempting to do so immediately and more extensively in the evening. He reported difficulty getting the carpets to dry in the winter because windows cannot be opened and the HVAC system cannot be run as frequently without making the environment too cold for residents, and he confirmed that the dampness and odors have been an ongoing issue. He also stated that he does not keep a log of how often the ventilation system is run. These observations and statements show that the facility did not ensure adequate mechanical ventilation or effective odor control on the memory care unit, resulting in persistent dampness and strong mildew and urine odors in resident care areas.
Failure to Maintain Proper Ventilation in Smoke Room
Penalty
Summary
The facility failed to maintain an appropriate exhaust system to remove cigarette smoke from the indoor smoke room, resulting in smoke and odor permeating areas frequented by residents and staff. Multiple observations over several days showed that residents and staff entered and exited the smoke room, with several residents smoking inside. The odor of smoke was detected from the lobby entrance, throughout the hallway, and inside and outside the 300 Hall dining room. On one occasion, a visible haze of smoke was observed outside the smoke room. Two floor fans and two garage fans intended to ventilate the area were not turned on during these observations. Interviews with residents, staff, and facility leadership confirmed the presence of smoke odor and visible smoke in the hallways and dining areas. One resident reported smelling smoke in their room when the door was open, and a housekeeper and CNA both noted strong smoke odors and visible smoke outside the smoke room. The Maintenance Director acknowledged that the fans should have been operating but were either turned off by residents or not functioning due to a power issue. The Administrator confirmed that the exhaust fans were broken and that the smoke odor was more pronounced during colder weather when more residents smoked indoors.
Non-Operational Ventilation Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure operational ventilation systems in resident bathrooms for four rooms (106, 108, 114, and 115) out of fifteen occupied rooms on the 100 hall. During an inspection with the Maintenance Supervisor, it was noted that the ventilation system did not draw a single ply of toilet paper to the surface of the ventilation cover in these bathrooms, indicating the systems were not functioning properly. The Maintenance Supervisor confirmed these findings and also acknowledged that no routine checks had been conducted to verify the operational status of the ventilation systems.
Failure to Address Air Conditioning Malfunction and Resulting Unsafe Conditions
Penalty
Summary
The facility failed to properly monitor and intervene when the air conditioning unit in the Chronic Confusion or Dementing Illness (CCDI) unit became non-operational, resulting in excessively warm and humid conditions. Multiple staff members, including RNs, LPNs, and CNAs, observed that the unit became hot, with significant humidity causing condensation and wet, slippery floors. Staff attempted to manage the moisture by dry mopping the floors, but did not notify management or the maintenance department about the high temperatures and humidity during the evening and night shifts. The lack of timely communication delayed appropriate intervention. Staff interviews confirmed that the issue persisted across several shifts, with reports of extremely hot conditions, condensation on floors in hallways and dining areas, and water observed in resident rooms. The Director of Human Resources/Interim Administrator was eventually notified by housekeeping staff, who reported the ongoing problem. Maintenance was contacted the following morning, at which point fans and dehumidifiers were brought in, and additional equipment was purchased to address the malfunction. The deficiency was further substantiated by climatological data indicating high outdoor temperatures during the incident.
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