Failure to Implement Required Legionella Testing Under Water Management Plan
Penalty
Summary
The deficiency involves the facility’s failure to follow its own water management plan by not conducting required Legionella testing of the building’s water system. The Administrator stated that the facility had never tested its water for Legionella, despite having a written Water Management Plan that specifies Legionella distal site testing with an annual monitoring frequency. The facility entered into a contract with a new water management service on 03/01/2025, after the prior survey, and received Legionella testing supplies dated 05/06/2025, but no testing was performed. The Administrator reported being unaware of why the testing was not done, even though the facility was expected to follow its policy and water management plan. The Maintenance Director confirmed that the facility had not been tested for Legionella and physically presented the unused testing supplies provided by the water management service. The facility’s Water Management Plan, dated 03/17/2025, outlines a risk management strategy based on ASHRAE Standard 188, including identifying building water systems, conducting hazard analysis, establishing control locations and measures, and implementing verification and validation procedures. The plan specifically requires annual Legionella distal site testing as part of control validation and mandates written documentation of monitoring, compliance with control limits, corrective actions, and validation, to be maintained for at least three years. Despite these written requirements, the facility did not carry out the annual Legionella testing or generate the associated documentation, affecting all 55 residents residing in the facility.
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