Failure to Implement Effective Water Management and Infection Control for Legionella
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria in the water supply. Despite receiving water test results indicating elevated and increasing levels of legionella, the facility did not re-evaluate or update its water management risk assessment or plan, nor did it provide effective interventions to mitigate the risk. The facility also did not ensure that residents were prevented from accessing or using water from areas where legionella could be present, as evidenced by residents continuing to use sinks and showers in affected areas without appropriate filters or signage restricting use. The facility's water management risk assessment was outdated and lacked critical components such as summaries, acceptable control levels, and response procedures for positive legionella findings. Maintenance activities were inconsistently documented, with no evidence of routine maintenance or cleaning of showers, whirlpools, or flushing of water in unoccupied rooms as required. Water testing was limited to a single location, and when results showed a significant increase in legionella levels, there was no documented investigation or intervention. Staff interviews confirmed a lack of awareness of the severity of the test results, and there was no evidence that residents were assessed for symptoms of Legionnaires' Disease during the period of elevated risk, including those with respiratory symptoms or hospitalizations. Residents, including those with high-risk conditions such as tracheostomies, ventilator dependence, and those receiving dialysis, continued to use water sources that were potentially contaminated. Interviews with residents confirmed ongoing use of sinks and showers in areas where legionella was present, and staff confirmed that there were no effective restrictions or visual cues to prevent such use. The facility's infection surveillance system was also found to be ineffective, as it failed to track infections and monitor trends, and appropriate infection control techniques were not followed during wound care for at least one resident.
Removal Plan
- An all-staff in-service was completed on risks, signs and symptoms and interventions for legionella by the DON and IP Nurse #302.
- Water to each sink in all facility rooms was shut off to prevent accidental use by residents and staff. Gallon jugs of purified water were put in place to wash hands with dates and names on each.
- The DON/designee would audit employee call-offs weekly, monitoring for any symptoms related to legionella illness. Any concerns would be immediately reported to the Administrator and addressed by the Quality Assessment Performance Improvement (QAPI) committee as necessary.
- The facility contracted with PT enterprises to assist with the water management plan. PT enterprises took twelve water samples (four swabs and eight additional 250 ml potable water samples).
- Point of use filters for all water sources in the facility were ordered.
- The DON brought in hot and cold-water dispensers for use on the second and third floors. This water was provided for residents' use for any residents who did not want to drink bottled water and staff were responsible for bringing the water to residents. Additional bottled water was supplied to the fourth floor.
- The DON educated the weekend staff and agency staff working on-site on not using the room sinks or shower on the second floor, as well as signs and symptoms of legionella.
- A Legionella assessment data collection form was created in point click care (PCC), which included a set of vital signs, a review of potential symptoms of legionella, a place for a narrative, and a yes or no question as to whether or not the resident experienced more than three symptoms beyond their baseline.
- All nurses would be educated on this form. Any nurse not educated would not be allowed to work the floor until the education was completed. Nurses would complete this assessment on resident admission and with resident change of respiratory condition.
- New legionella filters were received and placed on the main floor bathroom sink, therapy room sink, room [ROOM NUMBER] sink faucet, shower heads on the second, third and forth floors, at the nursing station sinks on the second, third and forth floors and on the dialysis center sinks by Maintenance Manager #322.
- Legionella tests for six residents who were transferred from the facility for signs and symptoms of respiratory distress were completed.
- A contracted plumbing company ([NAME] Plumbing) came to the facility to evaluate appropriate adapters to fit on the sink filters. They also evaluated sanitation. The water remained off to the room sinks at this time.
- The DON/designee completed resident assessments (legionella assessment data collection form) for all facility residents. The resident assessments would continue to be conducted weekly by the DON/designee and/or Infection Preventionist. Any concerns would be immediately reported to the Administrator and Medical Director for follow-up.
- The facility Water Management Committee, including the Administrator, DON, IP #302, Maintenance Manager #322, Housekeeping/Laundry Supervisor, RT Director and Dietary Manager met to further discuss the facility's Water management -Legionella plan.
- The facility QAPI committee met to review any updates to the water management plan and complete audits.
- The facility new water management protocols included: a.) Each faucet and shower head aerator would be cleaned with an approved scale and lime build-up cleaner semi-annually to ensure proper water flow quarterly. b.) The hot water boilers would be set at 140 or greater. Facility staff would record the temperature of each hot water device weekly and adjust immediately if less than 140. To ensure compliance to policy, staff would retest the following day to confirm appropriate temperature. c.) Hot water holding tanks would be set at a minimum of 140 to inhibit the growth of Legionella and other opportunistic pathogens. Facility staff would record the temperature weekly and adjust immediately if less than 140 to ensure compliance. d.) Regular cleaning and changing of filters would be done per manufacturers' recommendations. The facility would remove scale and clean using approved cleaning agents semi-annually and changing the filters every six months or per manufacturer recommendations. Maintenance Manager #322 would audit monthly to ensure compliance and audits will be reviewed in QAPI meetings. e.) Weekly flushing of water would be added to housekeepers assignments which would consist of flushing for three minutes each faucet and showers also flush all toilets at least once every week. The supervisor would review documentation weekly to ensure compliance. Audits would be reviewed, and the facility would determine where the failure occurs during QAPI meetings. f.) If the facility experiences one or more positive cases of legionellosis, the facility would conduct semi-annual testing to determine if the water management plan (WMP) was effective in controlling legionella and the Maintenance Manager #322 will follow up with the vendor to determine failure to conduct and correct this. g.) For any positive legionella in the water, the facility would contact PT enterprises, to conduct testing on water samples, provide alternate water sources for bathing and patient care, inspect all faucets for built-up scaling and cleaning with appropriate cleaner and replace all filters on incoming water sources. h.) Legionella filters would be changed per manufacturers' recommendations.
- The facility received ordered parts which were being installed with a plan to have all installation of parts/filters completed.
Penalty
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Surveyors identified multiple infection control failures involving three residents. During tracheostomy care for a resident with chronic respiratory failure and a trach, an RN removed soiled gloves after handling the inner cannula and dressing and then donned sterile gloves without performing required hand hygiene between glove changes before cleaning the stoma and applying a new dressing. In a separate incident, an RN performed a finger-stick blood glucose test on a diabetic resident using a shared glucometer and returned the device to the medication cart without disinfecting it, despite facility policy requiring decontamination of shared glucometers. Additionally, a resident with an indwelling urinary catheter was observed seated with the catheter drainage bag lying directly on the floor, contrary to facility policy that catheter bags and tubing be kept off the floor.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A deficiency occurred when staff failed to follow enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident had severe cognitive impairment, required total assistance with ADLs, and had a care plan and MD orders specifying EBP due to the catheter. An EBP cart with PPE was available outside the room, but during observed catheter care a CNA did not don a gown, despite acknowledging that the resident was supposed to be on EBP. Facility policy required EBP for residents with urinary catheters for the duration of their stay.
A resident with toxic encephalopathy, Parkinson’s disease, and a gastrostomy, who was cognitively impaired and dependent for toileting and dressing, had active orders and a care plan requiring Enhanced Barrier Precautions (EBP) with gown and glove use during high-contact ADL care, toileting, and linen changes. Surveyors observed a CNA repeatedly entering and exiting the resident’s room, which was posted for EBP, without wearing a gown while providing perineal care, toileting assistance, dressing, and changing bed linens. The CNA acknowledged the resident was on EBP, that no PPE supply was available near the room, and that she did not wear a gown, contrary to the facility’s EBP policy requiring gowns and gloves for such high-contact care.
Surveyors identified multiple infection prevention and control failures involving several residents, including a resident with pneumonia and impaired cognition whose soiled linens and used brief were left on the floor during care, and residents with diabetes whose blood glucose checks and insulin administration were performed by LPNs who did not perform hand hygiene and did not properly disinfect shared glucometers between uses. Additional residents receiving oral and nasal medications had their medications prepared and administered by LPNs who did not wash their hands before or after resident contact or before reentering the medication cart. A severely cognitively impaired resident with a chronic sacral wound and an indwelling catheter, care planned for Enhanced Barrier Precautions, received high-contact care from two CNAs who did not don gowns and did not perform hand hygiene while changing briefs, handling catheter tubing and bags, and transferring the resident. The facility also failed to carry out its Legionella Water Management Program, as the Administrator confirmed that required Legionella testing of the water system was either limited to ice machines in one year or not performed at all in the following year, despite the presence of unused rooms with stagnant water.
An LPN failed to clean reusable vital sign equipment between two residents on enhanced barrier precautions, including one on contact precautions for Klebsiella pneumoniae, and reached into a red biohazard bin containing soiled gowns with bare hands after removing PPE. On a resident hallway, a linen cart was left uncovered with clean towels and gowns exposed, and a dirty towel with brown spots was found on top of the clean linen cart, with a bag of soiled items placed directly next to it on the floor. Staff later acknowledged that reusable equipment should be cleaned between residents and that linen carts should remain covered, consistent with facility infection control policies.
Infection Control Failures in Tracheostomy Care, Glucometer Disinfection, and Catheter Management
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices related to respiratory care, blood glucose monitoring, and indwelling urinary catheter management. One resident with chronic respiratory failure, COPD, asthma, chronic pulmonary edema, and a tracheostomy had physician orders for tracheostomy care every shift and a daily inner cannula change. During an observed tracheostomy care procedure, the RN donned PPE, washed her hands, and set up supplies, then removed the old inner cannula and dressing with gloved hands and disposed of them. After this, she removed her gloves and immediately donned a new pair of sterile gloves from the tracheostomy care kit without performing hand hygiene in between glove changes, then proceeded to clean around the tracheostomy stoma and apply a new split gauze dressing. The RN later confirmed she had not performed hand hygiene between glove removal and donning new gloves, despite the facility’s tracheostomy care policy requiring hand hygiene at that point. Another deficiency occurred during blood glucose monitoring for a resident with intact cognition, diabetes, morbid obesity, chronic kidney disease stage 5, and atherosclerotic heart disease, who used a walker and received insulin. An RN entered the resident’s room to check blood sugar, initially using the resident’s Dexcom G7 receiver, then obtained consent to perform a finger-stick blood glucose test. After completing the finger stick with a shared glucometer, the RN returned to the cart, placed the glucometer on the cart, unlocked the cart, and stored the glucometer inside without disinfecting it. The RN later confirmed that the glucometer was not cleaned after use and acknowledged that it should have been disinfected after use on this resident, as it was a shared device used for multiple residents on the same hall. Facility policy required the glucometer to be disinfected on all external parts following the disinfectant’s directions. A further deficiency was identified in the management of an indwelling urinary catheter for a resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus. The resident had a care plan indicating risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention, with goals that the resident show no signs or symptoms of urinary infection and that the catheter remain patent and without complications. Interventions included ensuring the catheter tubing and drainage bag were secured properly with a dignity cover in place. Physician orders directed that the #16 French indwelling catheter be changed every 30 days and as needed, and the MDS confirmed the catheter was in place. During observation, the resident was seated in a chair with the catheter bag lying directly on the floor, with no barrier in place. An LPN confirmed that the catheter bag was on the floor. The facility’s catheter-associated urinary tract infection prevention policy specified that catheter bags and tubing should be kept off the floor.
Plan Of Correction
Formatted text (without <text> tags or quotes): 1. On 5/6/26 Resident #9 was assessed by Director of Nursing and shows no ill effect related to the lack of hand hygiene after removing the inner cannula and split gauze dressing. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. Resident #19 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. Resident #28 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. Resident #79 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. 2. Like Residents are identified as residents who utilize a tracheostomy and no other like resident were identified. An audit will be completed by the Director of Nursing or designee utilizing the Trach Tube Cannula and Stoma Care Skills check off which were created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure licensed nurses are preforming tracheostomy care according to the facility policy. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are located below the bladder but not laying on the floor. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize a facility glucometer. An audit will be completed by the Director of Nursing or designee utilizing the Glucometer Decontamination Skills check-off which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure licensed nurses are disinfecting glucometers after use according to the facility policy. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the tracheostomy tube cannula and stoma care policy to include hand hygiene during the procedure and hand hygiene with glove changes. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy to include placement of urinary catheter bags. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Glucometer and PT/INR Decontamination Policy to include disinfecting the glucometer after use. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with tracheostomies to ensure licensed nurses are performing tracheostomy care according to the facility policy. This audit will be completed weekly for 4 weeks, beginning 5/14/26 to ensure licensed nurses are performing tracheostomy care according to the facility policy. Noncompliance noted during the audits will be corrected with licensed nurse re-educated with return demonstration. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, Director of Nursing or designee will complete an audit of all residents who utilize urinary catheters to ensure catheter bags are located below the bladder but not laying on the floor. This audit will be completed weekly for 4 weeks, beginning 5/14/26 to ensure catheter bags are located below the bladder but not laying on the floor. Noncompliance noted during audits will be corrected with catheter bags changed and relocated to below the bladder but not laying on the floor. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Glucometer Decontamination Skills check-off which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete 5 observations of licensed nurses weekly for 4 weeks, beginning 5/14/26 to ensure the glucometer is disinfected appropriately after use. Noncompliance noted during audits will be corrected with the glucometer disinfected appropriately after use. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including right hip fracture, dementia, insomnia, and anxiety disorder, had a Minimum Data Set assessment indicating severe cognitive impairment and dependence on staff for ADLs. The resident’s care plan documented the presence of an indwelling catheter for skin breakdown and urinary retention, with an intervention specifying that staff were to maintain EBP due to the catheter, and physician orders also directed that the resident be on EBP. During observation, an EBP cart stocked with PPE was present outside the resident’s room, but when a CNA provided catheter care, the CNA did not don a gown as required. In a subsequent interview, the CNA confirmed awareness that the resident was supposed to be on EBP and acknowledged not wearing a gown while providing care. Review of the facility’s Isolation Precautions Process policy showed that EBP was to be used for residents with urinary catheters during their entire stay, which was not followed in this instance.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring proper use of personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted with diagnoses including toxic encephalopathy, Parkinson’s disease, and gastrostomy status, and was documented as moderately cognitively impaired, dependent on staff for toileting and lower body dressing, and frequently incontinent of bowels. The physician’s orders and active care plan required staff to use EBP, including gowns and gloves, during high-contact care activities such as ADL care, toileting, changing briefs, and linen changes due to the presence of a feeding tube. Surveyor observations showed that a CNA repeatedly entered and exited the resident’s room, which had an EBP sign on the door, without wearing a gown while assisting with toileting, perineal care, dressing, and changing bed linens. The CNA confirmed she was providing these high-contact care activities, verified that the resident was on EBP, and acknowledged that she did not wear a gown and that there was no supply of PPE near the room. A clear trash bag in the room contained discarded products but no used gowns. Review of the facility’s EBP policy dated 12/3/25 stated that, at minimum, staff must wear gloves and gowns during high-contact care activities including ADL care, toileting, and showers, which was not followed in this instance.
Widespread Infection Control and Water Management Failures
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices during resident care, medication administration, blood glucose monitoring, and environmental management. For one resident with pneumonia, muscle weakness, impaired cognition, and dependence on staff for toileting, a CNA was observed providing care with the room door open while soiled linens and a used adult brief were left on the floor. The CNA acknowledged that the dirty linens and brief were on the floor and stated she would pick them up after finishing care. The DON later confirmed that dirty linens were not to be placed on the floor and should be put in a bag. For residents with diabetes, staff did not follow hand hygiene and equipment disinfection policies during blood glucose monitoring and insulin administration. One cognitively intact resident with type 2 diabetes and acute kidney failure had an order for twice-daily blood sugar checks. An LPN removed a glucometer from the medication cart, entered the resident’s room, performed a fingerstick blood sugar check without cleaning the glucometer before use, then briefly wiped it with an alcohol pad afterward. The LPN returned the glucometer to the cart without performing hand hygiene before or after the procedure and confirmed that the device was used on multiple residents daily and that she had not cleaned it before use or washed her hands. Another resident with type 2 diabetes and chronic kidney disease, who received daily insulin, had a fingerstick blood sugar check and insulin administration performed by a different LPN who never washed her hands or used hand sanitizer before, between, or after entering and exiting the room. This LPN placed the glucometer on top of the cart, handled multiple insulin pens, administered insulin, then briefly wiped the glucometer for about 12 seconds before returning it to the cart, and confirmed she had not performed hand hygiene and believed this was the correct way to clean the glucometer. These practices did not follow the facility’s handwashing and cleaning/disinfecting policies or the Sani Wipe instructions requiring a two-minute wet time. Additional hand hygiene failures occurred during medication administration for residents with significant functional impairments. One severely cognitively impaired resident with radiculopathy, diabetes, and muscle weakness required assistance with ADLs. An LPN prepared 12 oral medications from the cart without hand hygiene, administered them along with a nasal spray, then returned the nasal spray to the cart without washing her hands before or after resident contact or before reentering the cart. Another cognitively intact resident with Parkinson’s disease and chronic kidney disease, who required ADL assistance, received 10 medications prepared in applesauce by a different LPN who also did not wash her hands before preparing the medications, after administering them, or before accessing the cart again to prepare medications for the next resident. These actions were inconsistent with the facility’s handwashing policy requiring hand hygiene before and after resident care and invasive procedures. The facility also failed to follow Enhanced Barrier Precautions (EBP) for a resident with severe cognitive impairment, a chronic sacral wound, and an indwelling catheter, who was care planned for EBP due to chronic wounds and device use. Two CNAs provided high-contact care, including a brief check and change, emptying the catheter bag, disconnecting and reconnecting catheter tubing, draining urine, dressing the resident, and transferring the resident via mechanical lift, without donning isolation gowns and without performing hand hygiene before, during, or after care. One CNA acknowledged the presence of an EBP sign at the room entrance instructing staff to wear gloves and a gown for high-contact activities such as transferring and device care, and both CNAs confirmed they had not worn gowns or performed hand hygiene. These actions did not comply with the facility’s EBP and handwashing policies. In addition to direct care issues, the facility did not implement its Legionella Water Management Program as written. The Administrator confirmed that in one year the facility only tested ice machines and did not perform required Legionella testing of the broader water system, and in the following year no Legionella testing was completed at all. The Administrator further confirmed that the facility used city water and that, despite contacting the water company, no Legionella testing was performed. The Administrator also acknowledged that there were empty resident rooms with private bathrooms and sinks where water could remain stagnant and that these areas were not tested in either year. These practices did not align with the facility’s Legionella Water Management Program policy, which required identification and monitoring of areas in the water system where Legionella could grow and spread, including storage tanks, water heaters, filters, aerators, showerheads, hoses, misters, humidifiers, and fountains, and required at least annual review of the program.
Failure to Clean Reusable Equipment and Maintain Clean Linen Storage
Penalty
Summary
The deficiency involves failures in infection prevention and control related to reusable equipment cleaning and linen handling. One resident with sepsis, sarcoid myocarditis, an indwelling urinary catheter, and Klebsiella pneumoniae was on enhanced barrier precautions and contact precautions. Another resident with onychogryphosis and moderately impaired cognition was on enhanced barrier precautions due to a suprapubic catheter. During observation, an LPN obtained vital signs, including pulse oximetry, thermometer, and blood pressure measurements, from the first resident and then from another resident without cleaning the reusable equipment between residents. The LPN removed her gown and gloves and, when attempting to dispose of them in a red biohazard bin where the bag had fallen, reached into the bin with bare hands despite multiple dirty gowns being present, and later confirmed she should have worn gloves and cleaned the equipment between residents. Additional observations on the F Hallway showed improper linen storage and proximity of soiled items to clean linen. A three-tier linen cart was observed with its front cover flap left open, exposing all towels and gowns to the air; a CNA confirmed the flap should always be down covering the linen. Later, the housekeeping supervisor observed a dirty white towel with brown spots placed on top of the clean linen cart and a dirty bag on the floor directly next to the linen cart containing gloves and a gown, and confirmed these findings. The DON confirmed that staff should be cleaning all reusable equipment between residents. Policy reviews showed that facility infection control policies required gloves when there is potential contact with blood or body fluids and required that reusable equipment not be used for another resident until appropriately cleaned and reprocessed.
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