Failure to Implement Legionella Water Management Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the absence of a water management program to mitigate the growth and spread of Legionella. The maintenance director reported that he checked the in-line water heater temperature every morning and maintained it at 117–118°F, despite the requirement for water temperatures to be 122–125°F for Legionella control. He also stated that no chemicals were added to the water for Legionella prevention, the building’s water was not tested for chlorine levels, and there was no formal plan or documentation for flushing stagnant water in empty rooms, even though he or housekeeping sometimes ran the water and flushed toilets. Review of water heater temperature logs from November 2025 through February 2026 showed the water heater was consistently maintained at 117°F. A city water employee confirmed that chlorine testing was performed daily at a nearby upstream facility but not at this nursing home. The DON/infection preventionist stated she expected maintenance to follow federal guidelines for Legionella prevention, and the administrator similarly stated she expected maintenance to follow guidelines to prevent Legionella and acknowledged there had been a staff changeover with no one monitoring that the process was being done. The administrator further stated there was no formal process for running stagnant water or ensuring water temperatures were at levels needed to kill Legionella, and that she was responsible for ensuring the water management process was followed. Review of the facility’s Infection Prevention and Control Policy dated October 2025 showed it did not contain information regarding Legionella management and prevention. These findings demonstrated that the facility lacked a formal, implemented water management program for Legionella as part of its infection prevention and control program, with the potential to affect all residents, staff, and visitors.
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