Failure to Maintain Operational Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation systems in resident bathrooms were operational in 11 out of 21 occupied bathrooms located on the south hallway. During an observation conducted with the Administrator and Maintenance Director, it was found that the ventilation system in these bathrooms was not functional, as evidenced by the inability of the system to draw a single ply of toilet paper to the surface of the ventilation cover. The Maintenance Director confirmed that the ventilation systems had not been routinely checked for proper function in these areas and that only one check had been performed since the Maintenance Director began employment in October 2024. Further review of facility records revealed that the last documented check of the ventilation systems facility-wide was on 11/24/25, with no other documentation available regarding ongoing checks. The facility's policy requires the Maintenance Director to maintain documentation of all inspections, tests, and maintenance of the HVAC system. The Administrator confirmed that staff should have been checking the ventilation system at least monthly, and ideally weekly, to ensure proper operation, but this was not done.