Failure to Maintain Clean and Sanitary Resident Room Vents
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for four residents by not ensuring that the heating and cooling vents in their rooms were free from a black mold-like substance. Observations on the specified date revealed that the vents in the rooms of these residents were visibly covered in this substance, with some also present on adjacent ceiling tiles. Multiple residents reported that the vents had appeared this way for several months, and at least one resident stated he had complained about the issue but could not recall to whom. None of the residents involved had documented pulmonary diagnoses or reported current respiratory symptoms. Interviews with staff, including a nurse, CNA, housekeeper, and the maintenance director, revealed a lack of clarity regarding responsibility for cleaning the vents. The nurse and CNA, both regularly assigned to the affected hall, had not noticed the black substance and were unsure whether housekeeping or maintenance was responsible for vent cleaning. The housekeeper stated that vent cleaning was not part of housekeeping duties and believed it was handled by maintenance. The maintenance director acknowledged that he had noticed the issue during the winter months and was in the process of cleaning the vents but had not completed the task. The facility's policy on providing a homelike environment requires a clean, sanitary, and orderly setting for residents. However, care plan reviews for the affected residents did not address the need for a clean environment or any respiratory issues. The ADON confirmed that maintenance was responsible for vent cleanliness and emphasized the importance of clean vents to prevent respiratory issues, particularly for residents with chronic pulmonary conditions.