Failure to Maintain Operational Ventilation in Resident Bathrooms
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.
Penalty
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Bathroom exhaust vents were not functioning in multiple resident rooms on the 100 and 200 halls, with surveyors observing no air movement at the ceiling vents in both occupied and unoccupied bathrooms. An MTC confirmed the ventilation problem and stated the vents were usually checked weekly, but there was no documentation to verify those checks.
Inadequate ventilation was identified throughout the facility when surveyors observed resident room windows on multiple floors screwed shut and unable to open, with no screens present. Hallway HVAC was present but not functioning in some areas, and only some resident rooms had AC units. Staff stated the building was not fully equipped with AC, that the windows were kept shut due to security concerns, and that repair recommendations for non-functioning AC units had been pending corporate approval.
Improper Airflow in Soiled Laundry Rooms: During the annual survey, a strong odor was noted in the soiled laundry rooms because the mechanically operated ventilation systems serving the two soiled laundry rooms did not have negative pressure airflow. On a follow-up tour, a window in one soiled laundry room was open to provide air circulation, and the Maintenance Director stated the roof exhaust fans would be reassessed.
Inadequate ventilation above the dish machine allowed steam to rise and hit the ceiling tiles over the dishwashing area. Staff observed bowed, peeling ceiling tiles, exposed yellow foam insulation, and a disrepair area around the ventilation duct, and the Maintenance Director stated the damage was caused by steam from the dish machine and had required repeated tile repairs.
Nonworking Bathroom Ventilation in 10 Resident Rooms: Surveyors observed that the bathroom vents in 10 resident rooms did not function when tested with toilet paper. Maintenance staff later confirmed the vents were not working and was unaware of the problem, and could not provide bathroom vent check logs. Record review showed the facility policy required ventilation system audits to be maintained.
Bathroom ventilation was not functioning in eight sampled resident rooms, including rooms 102, 105, 107, 114, 119, 121, 204, and 206. Surveyors verified the issue with a one-ply tissue during screening and the environmental tour, and the FM confirmed the problem. The facility also lacked an HVAC policy and a preventative maintenance program, and its HVAC checklist only addressed filter checks.
Bathroom Exhaust Ventilation Not Functioning
Penalty
Summary
The facility failed to ensure resident bathrooms were well-ventilated for resident rooms on the 100 and 200 halls, affecting 14 sampled residents in a facility with a census of 55. During multiple observations, surveyors found that the ceiling exhaust vents in bathrooms for several resident rooms were not moving any air, as shown by a single ply of toilet tissue held up to the vent not moving. These observations were made in both occupied and unoccupied rooms, including rooms occupied by Residents 14, 46, 26, 64, 42, 43, 48, 22 and 61, 40 and 38, 4, and 6 and 17, as well as one unoccupied room. An interview on 6/4/26 at 11:00 AM with the Maintenance Director confirmed the bathroom exhaust ventilation was not functioning. The Maintenance Director stated the ventilation was usually checked weekly, but there was no documentation to confirm those efforts.
Inadequate Ventilation in Resident Rooms and Hallways
Penalty
Summary
The facility failed to ensure adequate ventilation by opened windows, mechanical ventilation, or a combination of the two throughout the building. Survey observations on multiple days found that all resident room windows on the 1st, 2nd, and 3rd floors had screws in them that prevented them from being opened, and there were no screens in the resident room windows. Internal temperatures on one observation day ranged from 77 degrees to 81 degrees while the outside temperature reached 85 degrees. The building had HVAC ventilation in the hallways, but not in resident rooms, and only some resident rooms had air conditioners. The vents on the 2nd floor hallway serving Rooms 201 through 215 were not blowing air, and a window air conditioner at the end of the hallway was in use. Interviews confirmed that the resident room windows were intentionally kept from opening. An LPN stated the windows had been screwed shut after someone may have tried to jump out of one, and that the 2nd floor gets hot, with fans provided if residents complain. The Director of Maintenance stated the building was not fully equipped with air conditioning, that only some rooms had AC because the electrical load could not handle units in every room, and that management directed him to keep the windows from opening because of concerns about people jumping the back fence and selling drugs at the windows. He also stated he had been told by BFSI to remove the screws, but his supervisor and corporate person told him the screws were to remain. He further identified two non-functional hallway AC units and said repairs had been delayed because all work required corporate approval. A mechanical service representative stated the facility had received repair recommendations for the non-functioning AC units since 4/9/26 and had not approved the repairs to date.
Improper Airflow in Soiled Laundry Rooms
Penalty
Summary
The facility failed to ensure proper airflow in the soiled laundry rooms. During the annual survey, a tour of the clean and soiled laundry rooms was conducted with the Healthcare Services Group Environmental Services Director, and a strong odor was noted in the soiled laundry rooms because the mechanically operated ventilation systems serving the two soiled laundry rooms did not have negative pressure airflow. During a follow-up tour with the Maintenance Director, a window in one of the soiled laundry rooms was observed open to provide air circulation. The Maintenance Director stated that the roof exhaust fans would be reassessed to ensure proper airflow from the mechanically operated ventilation systems.
Inadequate Ventilation Above Dish Machine Caused Ceiling Damage
Penalty
Summary
The facility failed to ensure adequate ventilation of steam released above the dish machine, and the steam was observed rising from the dish machine and hitting the ceiling tiles above the dishwashing area. During observation, the ceiling above the dish machine was bowed, peeling, and had yellow foam/insulation hanging from it. The ceiling around the ventilation duct from the machine left an approximately 4-inch rectangular hole the length of the duct and was in disrepair. A kitchen utility worker confirmed that the ceiling gets warped from the steam. During a kitchen tour with the Maintenance Director, the warped ceiling above the dish machine was again observed, and the Maintenance Director affirmed that the ceiling tiles were in disrepair and that the exposed yellow foam insulation was from degradation of the ceiling tiles. The Maintenance Director stated the insulation within the tiles was fire-rated and explained that the degradation was caused by inadequate ventilation of steam from the dish machine. The Maintenance Director also recalled repeatedly having to exchange and repair ceiling tiles in that area due to the steam and stated damaged ceiling tiles can cause issues if insulation falls into the area of the clean dishes.
Nonworking Bathroom Ventilation in 10 Resident Rooms
Penalty
Summary
The facility failed to ensure that the ventilation systems were operational in 10 resident bathrooms in Rooms 113 through 122. During a facility tour, surveyors observed that the bathroom vents in these rooms did not suck up one ply square of toilet paper, indicating they were not working. A later observation with Maintenance Staff confirmed that the bathroom vents in these resident rooms were not working, and the staff member was unaware of the problem and unable to provide resident bathroom vent check logs. Record review of the facility policy titled Ventilation System Check and Auditing, dated 3/8/2023, showed that ventilation system audits were to be maintained.
Nonfunctional Bathroom Ventilation in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure resident bathroom ventilation was functional in eight sampled resident rooms: 102, 105, 107, 114, 119, 121, 204, and 206. During the initial screening and again during the environmental tour, surveyors checked the bathroom ventilation in these rooms with a one-ply tissue and found it was not functioning. The Facilities Manager confirmed the ventilation was not functioning in those rooms and stated the facility did not have a policy to check resident bathroom ventilation for functionality or a preventative maintenance program for the HVAC system. Record review showed the facility's 2026 HVAC Service Checklist included filter checks but no mention of resident bathroom ventilation system checks, and the DON also confirmed the facility did not have an HVAC policy or preventative maintenance program.
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