Failure to Implement Comprehensive Water Management and Legionella Risk Assessment
Penalty
Summary
The facility failed to follow its own water management program by not identifying building water systems that require Legionella control measures and not assessing the level of risk posed by hazardous conditions in those systems. During the survey, the facility was unable to provide documentation or evidence of a risk assessment or identification of specific water systems at risk for Legionella, as required by their policy. The only information provided consisted of a log for water flushing in unoccupied rooms, a general water management program policy, and screenshots of water flushing logs. The policy referenced a diagram (Figure A) for system identification, but no such diagram was attached or available. Interviews with the Administrator, Maintenance Director, and Regional Maintenance confirmed that no additional documentation or assessment existed beyond the flushing logs and policy. The staff stated that the water flushing logs constituted their assessment, but there was no written or otherwise documented evaluation of the facility's water systems or the risks associated with Legionella. This deficiency affected all 88 residents residing in the facility, as indicated by the facility census.