F0584

E

Failure to Maintain Clean and Sanitary Ceiling Vents in Resident Rooms

Tulare, California Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain clean and sanitary ceiling vents in all ten sampled resident rooms, compromising residents’ right to a safe, clean, comfortable, and homelike environment. On multiple observations conducted on the same day, surveyors noted that ceiling vents in each of the identified rooms had thick black dust-like debris, and in one room a vent had black mold-like debris. A resident reported not having seen housekeeping cleaning their room. Housekeeping staff, including the housekeeper and the Housekeeping Supervisor, acknowledged during concurrent observations and interviews that the vents were dirty, needed to be cleaned, and that dirt from the vents could fall on residents and get into their lungs. The Housekeeping Supervisor stated that both Maintenance and housekeeping were responsible for cleaning the vents and admitted the vents had not been cleaned in days and that they had missed cleaning them, allowing buildup.

The Maintenance Lead stated he did not do much cleaning and did not clean ceiling vents unless specifically instructed, indicating a lack of routine maintenance cleaning of vents. The Infection Preventionist reported not having noticed issues with dust, despite having monthly meetings with housekeeping for oversight, and stated that dusty or moldy vents would be a respiratory concern. Review of the facility’s Deep Clean Schedule and Room Rounds documentation showed no instructions for cleaning ceiling vents. The facility’s Routine Cleaning and Disinfection policy referenced cleaning from top to bottom and focusing on visibly soiled surfaces but did not specifically address ceiling vents, contributing to the omission of vent cleaning and the resulting accumulation of dust and debris in resident rooms.