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 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.
Surveyors found that mechanical ventilation in a soiled utility room and in resident bathrooms on two halls was not functioning. A strong, pungent odor was present in the soiled utility room, and testing of the ceiling vents with tissue paper showed no suction. The maintenance supervisor confirmed the vents were non-functional and reported that a single unit controlled ventilation for the soiled utility room and both halls’ bathrooms, suggesting a possible belt issue. This failure had the potential to affect all residents on those halls.
Bathroom ventilation systems were not operational in several resident bathrooms, as the fans ran but did not draw a 1-ply square of toilet paper during observations. The Maintenance Director said the fans were only checked monthly by listening for operation, and the Maintenance Man was unaware the systems were not working. The Administrator confirmed the bathroom ventilation was not working and that there was no policy and procedures for the ventilation system.
A facility failed to ensure adequate ventilation in three resident personal bathrooms because the exhaust fans were not operating properly. During observation, no air flow was detected at the vents in three bathrooms, and tissue paper placed at the vents was not pulled in. The MTD stated he was not aware of the decreased air flow and could not explain the cause; a later work history report showed an exhaust fan inspection had been completed but did not identify which bathroom fans were checked.
Bathroom vents in rooms 200, 201, 203, 205, 207, 209, 211, and 213 were not functioning and were found with whitish, brown debris. Observations showed the vents did not draw up a 1 ply sheet of toilet paper, and the ADM and Maintenance Director confirmed the vents were not working and had not been checked in a few months.
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.
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.
Failure to Maintain Functional Mechanical Ventilation in Soiled Utility Room and Resident Bathrooms
Penalty
Summary
The facility failed to maintain functional mechanical ventilation for the [NAME] and North halls and the [NAME] soiled utility room. During observation with Maintenance Supervisor I, the soiled utility room was noted to have a strong, pungent odor. The mechanical ventilation in this room was tested by placing a piece of toilet tissue against the ceiling vent grate, and no suction was present, as the tissue did not cling to the grate cover. Maintenance Supervisor I confirmed that the vent was not functional. Mechanical ventilation in the resident bathrooms on the [NAME] and North halls was checked in the same manner and was also found to be non-functional. Maintenance Supervisor I confirmed that the same unit controlled ventilation for the soiled utility room and the [NAME] and North Hall bathrooms and stated that there might be an issue with the belt. This failure to maintain the mechanical ventilation system had the potential to affect all residents on the [NAME] and North halls.
Bathroom Ventilation Systems Not Operational
Penalty
Summary
The facility failed to ensure that ventilation systems were operational in residents' bathrooms in rooms 33, 34, 36, 39, 40, and 41 to prevent odors. During observations on 3/30/26 and again on 3/31/26, the bathroom fans were running but did not draw a 1-ply square of toilet paper, showing the ventilation was not functioning properly. In interview, the Maintenance Director stated that the bathroom ventilations were only checked monthly when cleaning the vents and that the fan was considered working if it could be heard running; the Maintenance Man stated he was not aware the bathroom ventilation systems were not working and confirmed the fans came on but did not pull the toilet paper. The Maintenance Director confirmed the ventilation system was not working, and the Administrator confirmed the bathroom ventilation was not working and that there was no policy and procedures regarding the ventilation system.
Bathroom Ventilation Fans Not Operational
Penalty
Summary
The facility failed to ensure adequate outside ventilation by window or mechanical ventilation for three of 12 residents’ personal bathrooms because the ventilation fans were not kept operational. During observation, three resident personal bathrooms were found to have no air flow present at the bathroom vents. The bathrooms were in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. During interview and observation with the maintenance director, tissue paper placed at the vents in the three bathrooms was not pulled into the vents, indicating decreased or absent air flow. In one bathroom, the maintenance director removed the vent cover and had to place his hand up to the wrist into the vent opening to detect any air flow. He stated he was not aware of the decreased air flow and could not explain the reason for it. A work history report later provided showed an inspection of exhaust fans had been completed, but it did not identify which specific resident personal bathroom exhaust fans were inspected.
Bathroom Ventilation Systems Not Functioning and Contaminated
Penalty
Summary
The facility failed to ensure bathroom ventilation systems were functioning and clean in rooms 200, 201, 203, 205, 207, 209, 211, and 213. Observations on 3/9/2026 and 3/10/2026 showed that the bathroom vents in these rooms did not draw up a 1 ply sheet of toilet paper, indicating the vents were not working. The vents also contained a whitish, brown substance and debris. Interviews with the Administrator and Maintenance Director confirmed that the bathroom vents in these rooms were not working, that debris was present in the vents, and that the ventilation system had not been checked in a few months with no record of the vents being checked.
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.
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