Failure to Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain a water management program designed to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. Although the facility had a policy titled 'Reducing the Risk of Legionella in Facility Water Systems,' which outlined steps such as establishing a Water Management Program Team, describing building water systems, and documenting all program activities, there was no documentation available to indicate that the water management program was being maintained. During the review, the assistant administrator/business office manager reported that only the Legionella Policy could be located, with no evidence of ongoing program activities or documentation as required by the policy. At the time of the deficiency, the facility had 26 residents, and the lack of documentation and program maintenance was confirmed through record review and staff interview.