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Based on observation, and interviews with facility staff, the facility failed to maintain exhaust fans in a safe, clean and operating effectively manner. This affected multiple rooms in the Pavilion area of the facility.

The findings include:

During the tour on 10/28/10, the following observations were made:

Room 521 - Bathroom vent has moderate amount of dust inside the vent, the bathroom exhaust fan is functioning.

Room 522 - Contact Isolation Room. Surveyor and staff donned protective coverings and entered room. Bathroom vent has moderate amount of dust inside the vent.



Room 525 - Exhaust in the bathroom not working.

Room 607 - The bathroom vent was very dusty and appeared to be closed. The exhaust vent in the bathroom was not working.

Room 612 - The bathroom vent was very dirty.

Room 616 - The bathroom vent was very dirty.

Room 437 - Large amount of black substance on the ceiling in front of the vent and directly above on the ceiling. Bathroom vent was dusty.

Room 435 - Faucet in the bathroom was very loose. Small amount of black substance located above vent, Bathroom vent was dusty.

In an interview with the manager of the Pavilion on October 28, 2010 at 11:30am., the manager noted that the facility has cleaned all the HVAC vents in the past three days. They were generally dirty and needed to be cleaned. The bathroom exhaust vents were not cleaned and those noted above need to be corrected. In addition an interview with the Maintenance Manager on October 28, 2010, revealed that exhaust filters were replaced regularly as noted in the exhaust vent log.