Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella. During a review of documents, it was found that the water management plan provided by the Director of Maintenance was for another facility, and the current plan could not be located following a change of ownership. The Director of Maintenance indicated an intention to adapt the incorrect plan for the facility, and the Nursing Home Administrator confirmed the absence of a current, facility-specific water management plan. This failure to develop and maintain a water management program was not in accordance with CDC guidelines, which require a detailed description of the water system, identification of hazardous conditions, and establishment of control measures and corrective actions. Additionally, the facility did not implement enhanced barrier precautions for a resident who required them. Observation revealed that an LPN was administering enteral feeding to a resident on enhanced barrier precautions without wearing a gown, despite signage and available personal protective equipment at the room. The LPN confirmed knowledge of the requirement but did not follow it. The resident had a physician's order for enhanced barrier precautions due to a PEG tube. These findings were confirmed in interviews with facility leadership.