F0880

E

Failure to Implement Ventilation-Based Infection Control and HVAC Filter Maintenance

Palm Springs, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement proper infection prevention and control standards related to its HVAC system and ventilation practices. During an unannounced complaint investigation focused on infection control, surveyors learned that the facility had experienced a COVID-19 outbreak in which approximately 20 residents and several staff members tested positive. COVID-positive residents were placed on isolation precautions and transferred to the B wing, but the Infection Preventionist (IP) stated she did not know how the HVAC units connected multiple rooms and that the ventilation system was not considered when placing COVID-positive residents. The IP also reported that the facility did not have a ventilation mitigation strategy or policy for airborne infections to minimize potential contamination between rooms sharing the same HVAC unit.

Observations and interviews with the Director of Maintenance (DM) revealed that several HVAC units served multiple resident rooms and other areas, with each room having vents and returns that recirculated air back into the system. The DM stated that when a resident was COVID-positive, the vent and return in that room should be covered and a portable air conditioning unit used with the door closed to prevent recirculation of air to other rooms; however, there was no indication that this was systematically done during the outbreak. The DM also stated that the facility used MERV 12 filters in the ventilation system, and that the last filter changes occurred in September 2025, but he could not locate documentation to verify that the filters had been changed as required.

Record review showed that national guidance from CDC/NIOSH, ASHRAE, the Occupational Health Branch, and CDC’s ventilation in healthcare settings emphasized the importance of ventilation, appropriate filtration (including recommendations for MERV 13–14 or higher where possible), and routine HVAC maintenance and documentation to reduce airborne infectious aerosol exposure and COVID-19 transmission risk. The facility’s own maintenance policy required visual inspection and replacement of HVAC filters at least every 90 days, with detailed documentation of all actions taken, and required the maintenance supervisor to participate in infection control education and follow guidelines for heating and ventilation systems. The facility’s infection prevention and control program and transmission-based precautions policies called for comprehensive infection detection, prevention, and control, individualized resident placement decisions, and adherence to national standards, but these policies did not translate into a ventilation-focused strategy or documented HVAC filter maintenance consistent with the facility’s stated requirements and referenced guidelines.