Inadequate Ventilation in Memory Care Unit Bathrooms
Summary
The facility failed to ensure that the mechanical ventilation in the bathrooms of the Memory Care Unit (MCU) was functioning properly, affecting all 9 resident rooms on the unit. During an observation, a strong and stale urine odor was noted upon entering the MCU, and further inspection revealed that the bathroom vents were unable to pull up a single ply of toilet paper, indicating inadequate ventilation. Interviews with staff, including the Licensed Practical Nurse (LPN), Director of Maintenance (DOM), and Director of Housekeeping (DOH), confirmed that the vents were not functioning and were not regularly checked or cleaned. The facility's maintenance procedures were found to be lacking, as there were no regular maintenance rounds performed, and the Guardian Angel rounds conducted by facility managers did not include checks of the bathroom vents. The DOM confirmed that the ventilation system had not been checked, despite facility instructions to inspect exhaust fans monthly. Additionally, it was revealed that no Guardian Angel Rounds were performed on the MCU in May, and the rounds conducted in April and June did not identify any maintenance concerns. The Administrator confirmed the oversight in checking the ventilation system.
Penalty
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Surveyors found that mechanical ventilation in a soiled utility room and in resident bathrooms on two halls was not functioning. A strong, pungent odor was present in the soiled utility room, and testing of the ceiling vents with tissue paper showed no suction. The maintenance supervisor confirmed the vents were non-functional and reported that a single unit controlled ventilation for the soiled utility room and both halls’ bathrooms, suggesting a possible belt issue. This failure had the potential to affect all residents on those halls.
Bathroom ventilation systems were not operational in several resident bathrooms, as the fans ran but did not draw a 1-ply square of toilet paper during observations. The Maintenance Director said the fans were only checked monthly by listening for operation, and the Maintenance Man was unaware the systems were not working. The Administrator confirmed the bathroom ventilation was not working and that there was no policy and procedures for the ventilation system.
Bathroom vents in rooms 200, 201, 203, 205, 207, 209, 211, and 213 were not functioning and were found with whitish, brown debris. Observations showed the vents did not draw up a 1 ply sheet of toilet paper, and the ADM and Maintenance Director confirmed the vents were not working and had not been checked in a few months.
Surveyors found that bathroom exhaust vents in two resident rooms were not functioning, as they did not pull air in, despite facility logs indicating that one of these rooms’ vents had previously been checked and recorded as working. Review of the exhaust fan inspection log showed that only a small number of rooms in each hall were checked monthly over several months, and during an on-site observation and interview, the MD confirmed that the vents in the identified rooms were not operating.
Surveyors found that bathroom ventilation systems were not functioning properly in 12 of 27 occupied resident rooms when vents in those bathrooms failed to draw a 1‑ply piece of toilet paper to the vent surface during testing with the MD and Administrator. Facility records showed that monthly exhaust fan checks had been documented as completed, but the log did not identify which rooms were tested or how many rooms were actually checked, and the last recorded check lacked room-specific detail despite multiple rooms having inadequate ventilation.
Bathroom ventilation was not operational in seven resident bathrooms, including rooms 120, 301, 303, 305, 308, 309, and 313. Surveyors observed the issue during two tours, and WM confirmed the vents should have been working. WM stated the HVAC vendor reported frozen coils due to cold temperatures, and the vents were not checked when temperatures dropped below freezing; the most recent vent log showed the last check was completed in October 2025.
Failure to Maintain Functional Mechanical Ventilation in Soiled Utility Room and Resident Bathrooms
Penalty
Summary
The facility failed to maintain functional mechanical ventilation for the [NAME] and North halls and the [NAME] soiled utility room. During observation with Maintenance Supervisor I, the soiled utility room was noted to have a strong, pungent odor. The mechanical ventilation in this room was tested by placing a piece of toilet tissue against the ceiling vent grate, and no suction was present, as the tissue did not cling to the grate cover. Maintenance Supervisor I confirmed that the vent was not functional. Mechanical ventilation in the resident bathrooms on the [NAME] and North halls was checked in the same manner and was also found to be non-functional. Maintenance Supervisor I confirmed that the same unit controlled ventilation for the soiled utility room and the [NAME] and North Hall bathrooms and stated that there might be an issue with the belt. This failure to maintain the mechanical ventilation system had the potential to affect all residents on the [NAME] and North halls.
Bathroom Ventilation Systems Not Operational
Penalty
Summary
The facility failed to ensure that ventilation systems were operational in residents' bathrooms in rooms 33, 34, 36, 39, 40, and 41 to prevent odors. During observations on 3/30/26 and again on 3/31/26, the bathroom fans were running but did not draw a 1-ply square of toilet paper, showing the ventilation was not functioning properly. In interview, the Maintenance Director stated that the bathroom ventilations were only checked monthly when cleaning the vents and that the fan was considered working if it could be heard running; the Maintenance Man stated he was not aware the bathroom ventilation systems were not working and confirmed the fans came on but did not pull the toilet paper. The Maintenance Director confirmed the ventilation system was not working, and the Administrator confirmed the bathroom ventilation was not working and that there was no policy and procedures regarding the ventilation system.
Bathroom Ventilation Systems Not Functioning and Contaminated
Penalty
Summary
The facility failed to ensure bathroom ventilation systems were functioning and clean in rooms 200, 201, 203, 205, 207, 209, 211, and 213. Observations on 3/9/2026 and 3/10/2026 showed that the bathroom vents in these rooms did not draw up a 1 ply sheet of toilet paper, indicating the vents were not working. The vents also contained a whitish, brown substance and debris. Interviews with the Administrator and Maintenance Director confirmed that the bathroom vents in these rooms were not working, that debris was present in the vents, and that the ventilation system had not been checked in a few months with no record of the vents being checked.
Nonfunctioning Bathroom Exhaust Vents in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of adequate outside ventilation in resident bathrooms, as required by licensure regulation 175 NAC 12-007.04(D). Review of the facility’s “Exhaust Fan Annual Inspection Log For All Resident Room Restrooms Throughout Facility” dated from 10/15/2025 through 2/10/2026 showed that only three rooms per month were checked in various halls, and that one of the affected rooms in the 300 hall had been checked in December and logged as working. However, during observation on 03/02/2026 at 1:00 PM, the bathroom exhaust vents in two sampled rooms (one in the 300 hall and room 325) were found not to be functioning, as they did not pull air in. In a subsequent observation and interview on 03/03/2025 at 12:25 PM, the Maintenance Director confirmed that the bathroom vents in these rooms were not functioning and were not pulling air in. No information was provided in the report about the medical conditions or histories of the residents occupying the affected rooms at the time of the deficiency.
Failure to Maintain Operational Bathroom Ventilation Systems in Multiple Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident bathroom ventilation systems were operational as required by licensure regulation 175 NAC 12-007.04D. Facility documentation titled “Exhaust Fans” dated as completed on 1/28/26 instructed staff to check all exhaust fans in bathrooms and other specified areas and to verify that airflow was sufficient to hold a piece of paper to the vent when operating. However, during an observation conducted with the Maintenance Director (MD) and the Administrator, the ventilation systems in resident bathrooms in rooms 1, 5, 10, 11, 15, 16, 17, and 18 on the East hall and rooms 1, 2, 3, and 4 on the South hall did not draw a 1‑ply square of toilet paper to the surface of the ventilation cover, indicating that the systems were not working properly at that time. During interview, the MD confirmed that the ventilation systems in these 12 resident bathrooms were not functioning properly, as evidenced by the failure to draw the toilet paper to the vent surface. The MD also confirmed that monthly checks of the ventilation system had been marked as completed in the electronic Exhaust Fan documentation on 1/28/26, but there was no record specifying which rooms had been tested or how many rooms had been completed. The MD acknowledged that the last documented check of the ventilation systems was on 1/28/26 and that the documentation did not identify the specific rooms where exhaust fans had been checked. The facility census at the time was 33, and 12 of 27 occupied resident rooms were found to have non-functioning or insufficient bathroom ventilation.
Nonfunctioning Bathroom Ventilation in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure bathroom ventilation systems were operational in seven resident bathrooms, including rooms 120, 301, 303, 305, 308, 309, and 313, out of 24 resident rooms sampled in a facility with a census of 60. During the initial tour on 1.21.2026, surveyors observed that the bathroom ventilation was not functioning in these seven rooms. On a later tour on 1.26.2026 with Water Management, the same bathrooms were again observed to have nonfunctioning ventilation. In interview, Water Management confirmed the bathroom ventilation was not working in those rooms and stated it should be functioning. Water Management also confirmed the HVAC service company had been notified and reported the bathroom vents were not working because cold temperatures caused the coils to freeze. It was further confirmed that the bathroom vents were not checked when temperatures dropped below freezing, and the issue would have been identified when the vents were checked that month; the vents were checked quarterly. A record review showed the most recent bathroom vent check was completed in October 2025.
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