Failure to Maintain Emergency Water Supply and Water System Oversight
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program by not ensuring an appropriate emergency water supply and by lacking knowledge and oversight of the building's water system. During interviews, the Director of Maintenance was unaware that the facility was responsible for testing the internal water system for Legionella and other waterborne pathogens, stating that no such testing had been conducted during his two-year tenure. Additionally, he reported that aerators in residents' rooms had not been changed and that plumbing maintenance was only performed in response to emergencies, not as part of routine preventive measures. Observation in the basement revealed only 11 five-gallon containers of water and 4 empty containers, which was significantly below the recommended emergency water supply of one gallon per person per day for three days, given the facility's capacity of 29 residents and 10 staff per day. The Director of Maintenance confirmed that the emergency water supply was used for daily operations and that recent deliveries from the contracted water supplier were insufficient. Staff were unaware of the required emergency water supply amount, and no documentation or diagrams of the water system were available.