Failure to Maintain Adequate Ventilation and Environmental Hygiene
Penalty
Summary
Surveyors observed that the facility failed to maintain proper ventilation in six resident rooms and the main hall, resulting in inadequate air circulation and environmental hygiene. Specifically, bathroom ventilation fans were found to be non-operational in several rooms, and shared bathrooms had a heavy urine odor with exhaust vents that did not function, as confirmed by maintenance staff using tissue paper tests. Additionally, hallway ceiling vents and grates were covered in excessive dirt and debris, including blackened substances and thick, furry matter. These issues were confirmed during facility tours with the Maintenance Director Assistant, Housekeeping Director, Administrator, DON, and corporate staff. Interviews with facility staff revealed that although air filters were changed monthly, other aspects of ventilation maintenance, such as cleaning vents and ensuring fan operation, were not adequately addressed. The Administrator noted staffing shortages in the maintenance department, which contributed to the inability to keep up with required maintenance tasks. Maintenance records reviewed for the past year only documented filter changes, with no further details on other ventilation system upkeep.