Failure to Implement and Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement an effective water management program for the prevention, detection, and control of waterborne contaminants, specifically Legionella. According to the report, the facility's water management plan, which is contracted to an outside company, outlines procedures such as routine control measures, inspection of plumbing and hot water systems, quarterly cleaning of aerators, and regular water testing. However, documentation and staff interviews confirmed that the facility did not ensure ongoing water testing and compliance with its own water management plan, as the last recorded water test was completed on February 18, 2023. This deficiency was identified through observation, policy review, and staff interviews, which revealed that the facility did not adhere to CDC and CMS guidelines requiring regular risk assessments, implementation of water management programs, and documentation of testing and corrective actions. The Environmental Director and Nursing Home Administrator confirmed the lapse in water testing and compliance, indicating a failure to follow established protocols for minimizing the risk of Legionella and other waterborne pathogens in the facility's water system.