F0880

F

Failure to Maintain Effective Water Management and Infection Control Surveillance

West Bloomfield, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain and implement an effective water management and infection prevention and control program, including control of Legionella and other opportunistic premise plumbing pathogens. Surveyors observed a functional hopper in the soiled laundry sorting room that produced discolored water for several seconds before running clear. In the boiler room, one boiler was observed at 128°F and the second at 122°F, despite facility documentation indicating usual boiler settings of 150°F and CDC guidance in the facility’s materials stating that hot water should be stored above 140°F and recirculated hot water should not fall below 120°F. The facility’s Legionella Environmental Plan binder lacked a flow diagram and written description of how water travels through the building, despite the written policy requiring description of building water systems using flow diagrams and written descriptions.

The Assistant Maintenance Supervisor (AMS) reported that the Maintenance Director had left suddenly two weeks earlier and that there was no water management team to their knowledge. The AMS stated they were not involved in the water management plan, were unsure of the Maintenance Director’s responsibilities regarding the plan, and that flushing of tubs, hoppers, and eyewash stations was done weekly based on TELS notifications, without keeping logs. The AMS also indicated that the hopper in the laundry room was not part of their flushing routine. The Nursing Home Administrator (NHA) stated that the water management team previously consisted of the NHA, DON, Infection Preventionist, and Maintenance Director, and that the AMS was now assuming those responsibilities. When asked about formal water management meetings, the NHA acknowledged that the team needed to meet and did not dispute that the last documented minutes were from 2024, with no documentation of a 2025 meeting and no additional water management documentation beyond what was in the binder.

The facility’s infection control surveillance program was also found to be deficient. The Infection Control Preventionist (ICP) reported no recent outbreaks or trending infections but acknowledged that the surveillance program was not ongoing or continuous and was a month behind. The line listing lacked key information such as type of infection, duration of treatment, and location, and McGeer’s criteria were not provided or implemented. When surveyors requested laboratory results, clinicians’ rationale for antibiotic use, and documentation of McGeer’s criteria for several residents, the requested materials were not available. The ICP stated they had been working as a floor nurse due to staffing shortages, leaving the infection control program noncompliant except for one month when staffing allowed them to focus on their hired role, and reported they had not been offered assistance or support and had been denied additional help and training from corporate staff after orientation. No additional information was provided at survey exit.