Incomplete and Unimplemented Legionella Water Management Plan
Penalty
Summary
The facility failed to maintain a complete and compliant water management plan for Legionella, as required by federal regulations. The Director of Plant Operations confirmed that the only monitoring conducted was periodic water testing for Legionella, with the last test occurring over a year prior. The facility's water management plan was missing essential elements such as flow diagrams, identification of risk areas for Legionella growth, and specific control measures. Additionally, there was no documentation of monitoring or interventions related to control measures, and the plan did not include an assessment to identify where Legionella could grow and spread. The facility's policy required random testing of at least three water supply sources twice per year, but there was no evidence that this was being followed. The most recent Legionella water testing report recommended ongoing regular monitoring, but there was no documentation to show that water testing had been conducted since the last recorded date. The facility census at the time was 40 residents, all of whom were affected by the lack of a comprehensive and properly implemented water management plan.