Failure to Maintain Water Management Program for Infection Control
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program specifically related to water management. During a review of facility records, it was found that documentation was not maintained to prevent the growth of waterborne pathogens, and there was no adequate description of the building water system. The flow diagram did not identify the building's water systems for which Legionella control measures are needed, and there was no documentation describing the building water systems using text or testing protocols. The Maintenance Director confirmed that the facility did not maintain the required water management program. This deficiency had the potential to affect all residents residing in the facility, with a census of 116 at the time of the survey.