Failure to Conduct Required Legionella Water Testing
Penalty
No penalty information released
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 maintain its infection prevention and control program by not conducting required Legionella water testing as outlined in its Water Management Program. The program specified that Legionella testing should occur quarterly or annually, and that water samples should be tested and results kept within guidelines. Record review and staff interviews revealed that the Maintenance Director, who was responsible for the Water Management Program, had not ensured that Legionella testing was performed as required and was unaware if the town conducted such testing. Additionally, the Administrator was not aware of whether Legionella testing had been completed or if any results were available at the time of the survey.