Deficient Water Management Plan and Inadequate Flushing Practices
Penalty
Summary
The facility failed to effectively create and maintain a comprehensive Water Management Plan, impacting 144 residents. Upon review, the Water Management Plan was found to be missing several critical components, including a clear definition of the current Water Management Team Members, a written narrative of the potable water supply system, identification of high-risk areas for legionella development, and reference to accepted industry standards such as ASHRAE 188 or CDC guidelines. Additionally, the facility did not follow recommended practices for flushing low-use water systems, as evidenced by the flushing logs and CDC guidance reviewed. During an environmental tour, a hand sink in an unoccupied area was observed to have discolored water for several seconds upon flushing, and it was revealed that this area had not been occupied for at least 12 years. Interviews with maintenance staff confirmed the prolonged disuse of this area, and records indicated that flushing procedures may not have been adequate to address stagnant water in these pipes. These deficiencies increased the likelihood of waterborne pathogen development, including Legionella, due to inadequate water management and maintenance practices.