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F0923
E

Failure to Maintain Adequate Ventilation in Resident Bathrooms and Shower Room

Westminster, Colorado Survey Completed on 06-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate outside ventilation in one of two shower rooms and in nine of sixteen resident bathrooms. Observations revealed that the exhaust fan in the north shower room was not functioning and was covered in lint, while exhaust fans in several resident bathrooms did not generate air movement when tested. In some bathrooms, large holes around the vents exposed electrical wires, and in two bathrooms, the exhaust fans were missing entirely. These deficiencies were identified during an environmental observation conducted with the maintenance director, who confirmed the issues with the exhaust fans and noted that some were old and in need of replacement. The facility's policy required maintaining safe, functional, and comfortable indoor environmental conditions, including proper ventilation in all resident-use areas. However, the maintenance director stated that monthly monitoring was performed but had not identified the missing fans in two bathrooms. The nursing home administrator acknowledged the importance of functioning exhaust fans for air quality and indicated that the maintenance monitoring form did not include specific checks for the ventilation system at the time of the deficiency.

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