Failure to Maintain and Monitor Hot Water Tank Temperatures per Legionella Plan
Penalty
Summary
The facility failed to implement and maintain its Legionella Water Management Plan as required. Review of the plan revealed that hot water tanks supplying the nursing units and kitchen were to be maintained at a minimum of 140 degrees Fahrenheit, with weekly monitoring of flow and return temperatures. However, observations showed that the kitchen hot water tank reached only 122 degrees Fahrenheit, and the tanks for the 100, 200, 300, and 400-nursing units reached only 118 degrees Fahrenheit. Maintenance staff confirmed these temperatures did not meet the required threshold, and also verified that weekly temperature monitoring had not been completed for any of the tanks. Interviews with facility staff, including the Senior Administrator, confirmed the expectation that all hot water holding tanks should be maintained at or above 140 degrees Fahrenheit. The facility's Legionella Water Management Plan mission statement emphasized the importance of proactive steps to prevent Legionnaires' disease through proper water system management. Despite this, the facility did not adhere to its own protocols for temperature maintenance and monitoring, potentially affecting all 67 residents in the facility.