Failure to Implement Legionella Water Management and Monitoring Protocols
Penalty
Summary
The facility failed to implement its infection prevention and control measures for Legionnaires' Disease as outlined in its own Water Management Program and related policies. During an observation and interview with Maintenance, surveyors observed water testing being conducted only on a first-floor bathroom sink for pH, chlorine level, and temperature using a test strip and thermometer. Review of the Monthly Potable Water Log from late August 2024 through late November 2025 showed that pH, chlorine, and temperature monitoring was documented only for the first floor, even though the facility policy required testing pH in five sinks/showers per floor on a monthly basis. The Water Temperature Log did show daily temperature checks on all floors, but pH and chlorine testing were not performed or documented for upper floors. When questioned, Maintenance acknowledged that all floors should have been tested, monitored, and documented for pH and chlorine levels. Further observations and interviews revealed additional failures related to Legionella control. During a tour of the decorative water fountain at the front of the facility, Maintenance reported that the water pump had been turned off two days earlier and confirmed that the fountain water should be tested for Legionella annually per the facility’s Water Management Program, but this testing was not being done as required. In a subsequent interview, the Infection Nurse and Director of Facilities both confirmed that testing and monitoring for pH, chlorine, and water temperature should have been conducted on all floors, and that the decorative water fountain, where Legionella and other opportunistic waterborne pathogens can grow and spread, should have been tested. Review of the facility’s policy "Infection Prevention & Control Legionnaires' Disease" showed requirements for monthly pH monitoring in five sinks/showers per floor, annual Legionella testing of potable water, daily cleaning and disinfecting of decorative water features, Legionella culture testing of decorative water features by Maintenance, and monthly ice machine cleaning, all of which were not being fully implemented as observed and documented by surveyors.
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