Failure to Document Water Management Activities for Vacant Unit
Penalty
Summary
The facility failed to provide adequate documentation demonstrating the implementation of an effective water management plan, specifically for the vacant south unit (rooms 101-123). According to the facility's own Water Management Program Policy, a risk assessment is to be conducted annually, utilizing data such as water temperature logs and rounding observation data. During the recertification survey, the surveyor requested documentation of weekly temperature testing and flushing logs for the south unit but was informed that these records were not completed or available for the period from January 2025 to June 2025. The facility was only able to provide observation data for other units, not for the south unit in question. The deficiency was further substantiated by interviews with facility leadership, who confirmed that the responsible maintenance staff had not completed the required monitoring or documentation for the south unit. The absence of these records meant that the facility could not demonstrate compliance with its own water management protocols, potentially affecting all 67 residents residing in the facility at the time of the survey. No additional information or documentation was provided to address the lack of monitoring for the specified period.