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F0880
F

Incomplete Water Management Plan for Legionella and Waterborne Pathogens

Wilmington, Delaware Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a satisfactory water management plan to prevent the growth of Legionella and other waterborne pathogens. During document review and interview with the DPO (E3), the surveyor determined that the existing water management plan did not include a description and diagram of water flow in the facility, did not identify potential infection sites, and did not outline prevention and treatment plans. These deficiencies in the written plan were confirmed with E3. The survey findings were subsequently reviewed with the NHA (E1) on the same day, and later with the NHA (E1), DON (E2), ADON (E3), a regional nurse (E8), and regional reimbursement staff (E9, via phone) during the exit conference.

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Long-term care team reviewing survey readiness and plan of correction

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