Failure to Maintain Operational Bathroom Ventilation Systems in Multiple Resident Rooms
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to prevent pungent urine odors from permeating common areas and the dining room, affecting all residents. Observations and interviews confirmed the presence of these odors over several days, despite housekeeping efforts. The facility did not adhere to its policy on maintaining a homelike environment with pleasant scents.
Persistent Urine Odor in Common Areas and Dining Room
Penalty
Summary
The facility failed to ensure that pungent smells of urine did not permeate into common areas and the dining room, potentially affecting all residents. Observations over several days revealed a consistent presence of urine odor in the 300/400 hall nurses station/common area and dining room, as well as the 600 hallway. The urine smell was noted at various times of the day, with some areas also having a musty odor. Interviews with staff, family members, and the ombudsman confirmed the presence of these odors, despite the use of cleaning products and air fresheners by housekeeping staff. The facility's policy on maintaining a homelike environment, which includes pleasant and neutral scents, was not adhered to. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with ensuring a clean and odor-free environment. The facility census at the time was 51 residents, and the issue was documented under Complaint Number OH00152901.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
