Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement its water management program as outlined in its policy, specifically regarding the prevention of Legionella and other waterborne pathogens. Maintenance staff reported having a log for weekly flushing of certain outlets but were unaware of any routine facility-wide water management checks. Administrative staff confirmed that there was no system in place to monitor for standing water or to mitigate the risk of Legionella growth within the facility. The facility's policy required regular monitoring and recording of water temperatures at both hot and cold outlets, with specific temperature thresholds to prevent bacterial growth, and mandated that sporadically used outlets be flushed weekly. However, the required monitoring, recording, and mitigation activities were not being performed as specified. This lack of adherence to the water management policy placed the facility's residents at risk for exposure to Legionella and other waterborne pathogens.