F0880

F

Failure to Implement Legionella Water Management Controls and Involve IP in Program

Atco, New Jersey Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Facility staff failed to implement, maintain, and monitor control measures to prevent the growth of Legionella in accordance with the facility’s Water Management Program (WMP), CDC guidelines, and ASHRAE Guideline 12. During a tour of the skilled nursing section, surveyors observed three shower heads in the shower room, two of which were in use, and only one of those two had a filter in place. The Campus Maintenance Director (CMD) stated that CNAs may have removed a filter to get better water flow and that maintenance checked filters every three months, but he was unable to produce logs showing when shower head filters were checked or replaced. A provided “SNF Community Shower Room” log only showed a date when a new filter was installed, and the CMD could not explain what the log meant. CNAs reported no issues with low water pressure and confirmed that residents regularly received showers in the shower room and in private showers.

Surveyors also observed an ice machine in the dining room/pantry area with an inspection sheet indicating it had been cleaned and sanitized by the Heating, Ventilation and Air Conditioning Mechanic (HVACM) several months earlier. A filtration device attached to the water line for the ice machine had a handwritten date that appeared to be the installation date, and the CMD was unsure if the filter had been changed since then or what the manufacturer’s specifications were for changing the filter. The HVACM confirmed he had disassembled, sanitized, and reassembled the ice machine but had not changed the filter device at that time, stated the filter should have been changed, and indicated the filter device now needed to be ordered. The CMD acknowledged he could not provide logs or an ordering schedule for the ice machine filter and attributed missing audits and documentation in part to a terminated Maintenance Supervisor.

Interviews with leadership and clinical staff showed that the Infection Preventionist (IP) was not included in Legionella control measures despite the WMP and facility policy identifying the IP as part of the water management team. The IP/LPN reported having been the IP for about a year, stated she had no knowledge of any current Legionella issues in the building, and indicated that upper management and maintenance were handling Legionella. She recalled being told to provide general education on Legionella about a year earlier but had not been involved in remediation activities. The Licensed Nursing Home Administrator (LNHA) confirmed that the IP/LPN was responsible for staff education on Legionella but was not currently involved in remediation and had not been included in discussions about Legionella since he became LNHA. The LNHA also acknowledged that the WMP listed program team members who were no longer employed and that he was unaware of the magnitude of the facility’s Legionella history or the status of mitigation efforts when he assumed his role. Meanwhile, staff routinely used water from coolers and ice from the ice machine for residents’ drinks, meals, and medications, and residents confirmed receiving water with ice and regular showers, while the WMP required documented regular cleaning and filter changes for ice machines and showerheads when Legionella-positive samples were identified.

A review of the facility’s WMP dated mid-2025 showed that the current CMD and former executive leadership were listed as program team members, but it did not reflect current responsible individuals. The WMP identified ice machines, medical devices, shower heads, and hoses as devices at risk for Legionella contamination and required regular cleaning, filter changes per manufacturer specifications, and documentation of these activities. It also required regular cleaning, replacing or dismantling, disinfecting, and descaling of showerheads and hoses, and called for more frequent sampling and review when Legionella-positive samples were found outside control limits. The facility’s Legionella Water Management Program policy further specified that the water management team must include at least the IP, administrator, medical director, director of maintenance, and director of environmental services. Despite this, the LNHA could not provide documentation of completed NJDOH Communicable Disease Services recommendations prior to a recent sampling event and initially provided policies that he later acknowledged were not the actual WMP, underscoring that the WMP had not been updated to include current responsible team members or fully implemented as written.