Failure to Implement Legionella Water Management Program and Involve Infection Preventionist
Penalty
Summary
The facility failed to ensure its Legionella water management program, which is part of the infection prevention and control program, was implemented as written and included the participation of the infection preventionist. The written policy dated 1/2022 specified that the water management team must include the infection preventionist, the administrator, the medical director or designee, the director of maintenance, and the director of environmental services, and referenced a detailed description and diagram of the facility’s water system and identification of areas that could promote growth and spread of waterborne bacteria. Record review showed a 2025 cleaning schedule for shower heads with quarterly entries completed for January, April, and July, but no documentation for October. During interview, the infection preventionist stated they did not know they were on the water management team, and the administrator stated there was no diagram for a water management program and confirmed there was no documentation for October 2025 in the logbook. The administrator identified that 37 residents resided in the facility at the time of the survey.
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