Non-Operational Bathroom Exhaust Fans
Penalty
Summary
The facility failed to maintain operational bathroom exhaust fans in accordance with NFPA 101:2012 edition, Sections 19.5.2.1, 9.2, and NFPA 90A. During a facility tour, it was observed that 3 out of 7 resident room bathrooms did not have windows, and the exhaust fans were non-operational. These rooms were identified as 122, 126, and 218. An interview confirmed that the main exhaust fan for the section was down, affecting all bathrooms served by that unit. This deficiency had the potential to affect 50 residents.
Plan Of Correction
1/13/25 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: The maintenance Director has repaired exhaust fans in rooms 122, 126 and 218. See evidence attached. 2. Identification of residents who have the potential to be affected by the same deficient practice: All residents had the potential to be affected by the deficient practice. 3. Systemic changes to ensure that deficient practice does not recur: The U.S. FOIA (b) (6) was educated in maintaining heating, ventilation, and air conditioning in all patient rooms. The Maintenance Director/ designee will audit HVAC systems throughout the facility, in patient rooms every six months. Findings will be submitted to the Administrator for review. 4. Monitoring corrective actions: Corrective actions will be evaluated for effectiveness, and the plan of corrections will be integrated into the Quality Assurance Performance Improvement (QAPI) program. The Quality Assurance Performance Improvement Committee will review the bi-yearly audit on a Quarterly basis x 1 year to ensure compliance.