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F0880
E

Failure to Develop Legionella Water Management Program

Sulphur, Oklahoma Survey Completed on 04-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a water management program for Legionella, as required for infection prevention and control. Record review showed that no Legionella testing had been conducted according to the maintenance air and water temperature log. When requested, the administrator provided only an information packet on Legionella, which did not include a formal policy. The maintenance supervisor, who was recently hired, reported not having a detailed diagram of the facility, no water management program in place, and no training on Legionella, aside from receiving an information packet. The administrator confirmed that there was no Legionella water management policy available at the time of the survey. A total of 44 residents were reported to be residing in the facility during the time of the deficiency.

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