Failure to Implement Effective Water Management and Infection Control for Legionella
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria in the water supply. Despite receiving water test results indicating elevated and increasing levels of legionella, the facility did not re-evaluate or update its water management risk assessment or plan, nor did it provide effective interventions to mitigate the risk. The facility also did not ensure that residents were prevented from accessing or using water from areas where legionella could be present, as evidenced by residents continuing to use sinks and showers in affected areas without appropriate filters or signage restricting use. The facility's water management risk assessment was outdated and lacked critical components such as summaries, acceptable control levels, and response procedures for positive legionella findings. Maintenance activities were inconsistently documented, with no evidence of routine maintenance or cleaning of showers, whirlpools, or flushing of water in unoccupied rooms as required. Water testing was limited to a single location, and when results showed a significant increase in legionella levels, there was no documented investigation or intervention. Staff interviews confirmed a lack of awareness of the severity of the test results, and there was no evidence that residents were assessed for symptoms of Legionnaires' Disease during the period of elevated risk, including those with respiratory symptoms or hospitalizations. Residents, including those with high-risk conditions such as tracheostomies, ventilator dependence, and those receiving dialysis, continued to use water sources that were potentially contaminated. Interviews with residents confirmed ongoing use of sinks and showers in areas where legionella was present, and staff confirmed that there were no effective restrictions or visual cues to prevent such use. The facility's infection surveillance system was also found to be ineffective, as it failed to track infections and monitor trends, and appropriate infection control techniques were not followed during wound care for at least one resident.
Removal Plan
- An all-staff in-service was completed on risks, signs and symptoms and interventions for legionella by the DON and IP Nurse #302.
- Water to each sink in all facility rooms was shut off to prevent accidental use by residents and staff. Gallon jugs of purified water were put in place to wash hands with dates and names on each.
- The DON/designee would audit employee call-offs weekly, monitoring for any symptoms related to legionella illness. Any concerns would be immediately reported to the Administrator and addressed by the Quality Assessment Performance Improvement (QAPI) committee as necessary.
- The facility contracted with PT enterprises to assist with the water management plan. PT enterprises took twelve water samples (four swabs and eight additional 250 ml potable water samples).
- Point of use filters for all water sources in the facility were ordered.
- The DON brought in hot and cold-water dispensers for use on the second and third floors. This water was provided for residents' use for any residents who did not want to drink bottled water and staff were responsible for bringing the water to residents. Additional bottled water was supplied to the fourth floor.
- The DON educated the weekend staff and agency staff working on-site on not using the room sinks or shower on the second floor, as well as signs and symptoms of legionella.
- A Legionella assessment data collection form was created in point click care (PCC), which included a set of vital signs, a review of potential symptoms of legionella, a place for a narrative, and a yes or no question as to whether or not the resident experienced more than three symptoms beyond their baseline.
- All nurses would be educated on this form. Any nurse not educated would not be allowed to work the floor until the education was completed. Nurses would complete this assessment on resident admission and with resident change of respiratory condition.
- New legionella filters were received and placed on the main floor bathroom sink, therapy room sink, room [ROOM NUMBER] sink faucet, shower heads on the second, third and forth floors, at the nursing station sinks on the second, third and forth floors and on the dialysis center sinks by Maintenance Manager #322.
- Legionella tests for six residents who were transferred from the facility for signs and symptoms of respiratory distress were completed.
- A contracted plumbing company ([NAME] Plumbing) came to the facility to evaluate appropriate adapters to fit on the sink filters. They also evaluated sanitation. The water remained off to the room sinks at this time.
- The DON/designee completed resident assessments (legionella assessment data collection form) for all facility residents. The resident assessments would continue to be conducted weekly by the DON/designee and/or Infection Preventionist. Any concerns would be immediately reported to the Administrator and Medical Director for follow-up.
- The facility Water Management Committee, including the Administrator, DON, IP #302, Maintenance Manager #322, Housekeeping/Laundry Supervisor, RT Director and Dietary Manager met to further discuss the facility's Water management -Legionella plan.
- The facility QAPI committee met to review any updates to the water management plan and complete audits.
- The facility new water management protocols included: a.) Each faucet and shower head aerator would be cleaned with an approved scale and lime build-up cleaner semi-annually to ensure proper water flow quarterly. b.) The hot water boilers would be set at 140 or greater. Facility staff would record the temperature of each hot water device weekly and adjust immediately if less than 140. To ensure compliance to policy, staff would retest the following day to confirm appropriate temperature. c.) Hot water holding tanks would be set at a minimum of 140 to inhibit the growth of Legionella and other opportunistic pathogens. Facility staff would record the temperature weekly and adjust immediately if less than 140 to ensure compliance. d.) Regular cleaning and changing of filters would be done per manufacturers' recommendations. The facility would remove scale and clean using approved cleaning agents semi-annually and changing the filters every six months or per manufacturer recommendations. Maintenance Manager #322 would audit monthly to ensure compliance and audits will be reviewed in QAPI meetings. e.) Weekly flushing of water would be added to housekeepers assignments which would consist of flushing for three minutes each faucet and showers also flush all toilets at least once every week. The supervisor would review documentation weekly to ensure compliance. Audits would be reviewed, and the facility would determine where the failure occurs during QAPI meetings. f.) If the facility experiences one or more positive cases of legionellosis, the facility would conduct semi-annual testing to determine if the water management plan (WMP) was effective in controlling legionella and the Maintenance Manager #322 will follow up with the vendor to determine failure to conduct and correct this. g.) For any positive legionella in the water, the facility would contact PT enterprises, to conduct testing on water samples, provide alternate water sources for bathing and patient care, inspect all faucets for built-up scaling and cleaning with appropriate cleaner and replace all filters on incoming water sources. h.) Legionella filters would be changed per manufacturers' recommendations.
- The facility received ordered parts which were being installed with a plan to have all installation of parts/filters completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
The facility failed to fully document infection surveillance and RTW decisions during a COVID outbreak. Multiple staff members reported symptoms such as sore throat, headache, congestion, diarrhea, vomiting, fever, and cough, but the employee illness logs were incomplete and left the RTW date blank, with no indication they were tested for COVID or cleared per CDC guidance. At the same time, multiple residents were diagnosed with COVID and others had GI symptoms with unknown testing status. The IP said she worked infection control only a few hours per week and had not thoroughly reviewed the logs for trends, while the DON had not been reviewing the surveillance logs.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Infection Control Failures During Resident Care: Staff did not follow PPE, hand hygiene, and equipment-cleaning practices during care for several residents. An RN failed to clean a glucometer and basket after blood sugar checks, a CNA and a Central Supply staff member entered rooms with enhanced barrier precautions without PPE, and an LVN did not clean the glucometer or insulin vial, and did not properly perform hand hygiene during insulin administration and after emptying a urinal. Residents involved had significant cognitive impairment, diabetes, wounds, and other serious diagnoses.
Infection control failed during laundry services when staff reported using the same personal T-shirt for handling dirty laundry and then hanging clean laundry, while using disposable gowns only for laundry from a resident with an infection. The DON also acknowledged that the Infection Prevention Program policy was overdue for annual review, and the policy showed no indication of an annual review.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use and implementation of Enhanced Barrier Precautions (EBP) during wound care. One resident with an indwelling urinary catheter had an active order and care plan for EBP, and a door sign specifying that gown and gloves were required for high-contact resident care activities, including wound care and device care. During an observation, an RN and a CNA entered this resident’s room, performed hand hygiene, donned gown and gloves, and completed catheter care in accordance with the posted EBP instructions. However, after completing catheter care, the RN instructed the CNA that they could remove their gowns because EBP was “only for the catheter,” and both staff removed their gowns and gloves, performed hand hygiene, and then donned only clean gloves to perform a dressing change on the resident’s right heel and pinky toe, despite the door sign indicating gown and gloves were required for wound care. A second resident had multiple open wounds on both lower extremities that required cleansing, application of collagen with wound gel and alginate, and coverage with border gauze dressings. Progress notes documented that these wounds originated as skin tears and were slowly healing, and active wound care orders were in place. During an observation of wound care for this resident, an RN and a nurse aide performed hand hygiene and donned gloves but did not wear gowns. There was no EBP sign or PPE set up outside the room, and there was no order for EBP in the electronic medical record, even though the resident had open wounds requiring dressing changes. In interviews, the RN stated that EBP was required for chronic wounds such as pressure, venous, and arterial wounds, and that EBP for the first resident applied only to catheter care. The CNA reported that she relied on the door sign and believed she only needed to gown for catheter care, brief care, or toileting, and not for transferring if she was not in contact with the catheter. The Infection Preventionist explained that EBP was used for chronic wounds and indwelling devices and stated that staff would only need to gown when providing care to the Foley catheter, while the DON stated that EBP was for residents with devices or dressing changes to prevent MDROs and that staff should wear gown and gloves even when not providing direct catheter care. The facility’s written EBP policy specified that EBP applies to residents with chronic wounds and/or indwelling medical devices and that PPE for EBP is necessary when performing high-contact care activities, including wound care and medical device care, which was not consistently followed in the observed wound care encounters.
Incomplete COVID Surveillance and Return-to-Work Tracking
Penalty
Summary
The facility failed to ensure its infection prevention and control program documented employee illness monitoring, testing, and return-to-work decisions during a COVID outbreak. The report states that 7 of 9 staff members with symptoms of COVID were not documented as having been tested, their illnesses were not tracked to identify possible links between resident COVID cases and staff exposure or subsequent illness, and there was no indication when they could return to work according to CDC guidance. The January 2026 resident infection surveillance log showed 12 residents diagnosed with COVID during the outbreak and exhibiting symptoms including cough, runny nose, congestion, and wheezing. Five additional residents had loose stools and vomiting, but it was unknown whether they had been tested or found positive for COVID. The January 2026 employee illness log showed multiple staff call-ins for symptoms including sore throat, headache, congestion, dizziness, lightheadedness, diarrhea, vomiting, fever, sinus congestion, and cough, but the logs were not completed fully and the date returned to work was left blank each time. The infection preventionist stated she had been in the role for less than a year, worked infection control only 4 to 5 hours per week depending on staffing, and transferred staff illness information from the business office into the employee illness logs. She said staff were to be off work for at least 24 hours after vomiting, fever, or diarrhea resolved, but she had not thoroughly completed the surveillance logs or looked for trends or patterns. The DON stated she reviewed the IP's monthly data before QAPI meetings but had not been reviewing the surveillance logs since the new IP started. The facility's infection control and surveillance policies described monitoring infections for trends and managing infections through education and record keeping, and the return-to-work policy included guidance for suspected or confirmed COVID, but the report states there was no indication this return-to-work process followed CDC guidance.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for multiple residents during observed care and record review. Resident #7 had a diagnosis of type 2 diabetes mellitus and a BIMS score of 4, indicating severely impaired cognition. During an observation, RN A used a small amount of hand sanitizer for only a few seconds, checked the resident’s blood sugar, and did not clean the glucometer before placing it in the medication cart. RN A also used a purple basket to carry glucometer supplies into the resident’s room, placed it on the bedside table, and did not clean the basket before returning it to the medication cart. RN A stated the glucometer should be sanitized before and after each use and that not doing so could put the resident at risk of infection. Resident #32 had severe cognitive impairment and multiple injuries, including intracerebral hemorrhage, subarachnoid hemorrhage, fractured rib, fractured lower leg, fractured spine, and surgical and traumatic wounds. The care plan included enhanced barrier precautions. During observation, the resident’s room had an enhanced barrier precautions sign and the PPE station outside the door had only one glove and one gown. CNA A assisted with removing a brace from the resident’s right arm without using any PPE. CNA A stated that any time there was a PPE station, staff were supposed to use the PPE and that failing to do so could transfer something to another resident. Resident #95 had diagnoses including breast cancer, Asperger’s syndrome, protein-calorie malnutrition, anxiety, and hypokalemia, and the care plan directed staff to use gown and gloves during high-contact care activities that could transfer MDROs. During observation, the resident’s door had an enhanced barrier precautions sign, but staff entered the room without PPE while Central Supply assisted with pulling the resident up in bed. Central Supply stated PPE was required any time patient care was provided to the resident. Resident #101 had type 2 diabetes mellitus and an insulin order for lispro before meals for high blood sugars. During observation, LVN D did not perform hand hygiene before putting on gloves, did not clean the glucometer before checking the resident’s blood sugar, did not clean the top of the insulin vial before withdrawing insulin, performed hand hygiene for less than 5 seconds and did not cover the backs of her hands, and did not properly perform hand hygiene after emptying the resident’s urinal. LVN D also did not clean the glucometer or tray before placing them in the medication cart.
Infection Control Lapses in Laundry Services and Policy Review
Penalty
Summary
The facility failed to ensure appropriate infection control during laundry services and failed to review its Infection Prevention Program policy annually. During a laundry room tour and interview, other staff stated they put a personal T-shirt on over their clothes when handling dirty laundry and used the same T-shirt when hanging clean laundry. They also stated they used disposable gowns when handling laundry from a resident with an infection, but had no concerns about wearing the same clothing for clean and dirty laundry if the resident did not have an infection. The director of maintenance stated the facility used an external company for on-site laundry and housekeeping services and believed laundry staff wore gloves and a gown when handling dirty laundry, but was not concerned if no gown was worn as long as staff clothing did not touch the dirty clothing. The Bywood East Infection Control and Prevention Program policy dated 4/26/24 had no indication of an annual review, and the DON stated the infection prevention program policy was overdue for review.
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