F0908

F

Failure to Maintain Legionella Control Measures for Showerheads and Ice Machines

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement required Legionella control measures on resident showerheads and ice machines as directed by the New Jersey Department of Health (NJDOH) Communicable Disease Service (CDS) and as outlined in the facility’s Water Management Plan (WMP). NJDOH CDS written instructions dated 01/21/2025 required immediate installation of 0.2-micron biological point-of-use filters on any showerheads intended for use, or restriction of showers with use of sponge baths instead, and specified that filters must comply with ASTM F838. The same communication directed the facility to assess for additional point-of-use filters at fixtures with elevated aerosolization risk and to follow manufacturers’ recommendations for filter replacement. The WMP, dated 07/15/2025, identified showerheads, hoses, and ice machines as devices at risk for Legionella contamination and required regular cleaning and filter changes per manufacturer specifications, with documentation.

On the survey date, during an inspection of a resident shower room, the survey team, accompanied by the Campus Maintenance Director (CMD), a NJDOH CDS Water Systems Analyst, and a Local Health Department representative, observed that the resident showerhead did not have a 0.2-micron biological point-of-use filter in place. The CMD stated that CNAs sometimes removed the filters when water flow was low and that maintenance checked the filters every three months, but he could not produce logs to show when showerhead filters had been checked or replaced. The only record provided was a “SNF Community Shower Room” log indicating a date when a new filter was installed, which the CMD could not interpret. The LNHA reported he was aware filters needed to be checked and changed but relied on maintenance for the schedule and believed audits were being done.

During inspection of the ice machine near the resident dining area, the survey team observed a filter device labeled with an installation date of 02/04/2025. The CMD was unsure if the filter had been changed since that date and could not speak to the manufacturer’s replacement specifications. The Heating Ventilation Air Conditioning Mechanic (HVACM) confirmed he had disassembled, sanitized, and reassembled the ice machine in November 2025 and normally would change the filter cartridge, but on that occasion did not change the filter device. He acknowledged the filter device should have been changed and that he did not handle ordering, which he believed was the responsibility of a Maintenance Supervisor who had since been terminated. The CMD was unable to provide any logs or ordering records for the ice machine filter, citing frequent vendor changes and multiple people being involved. The LNHA acknowledged awareness of a history of Legionella issues at the facility and ongoing communication with NJDOH CDS, but he was unable to provide documentation of NJDOH CDS recommendations completed before a February 2026 sampling event and believed he was following the WMP despite the lack of documented compliance with required control measures for showerheads and ice machines.