Health inspection·February 27, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Legionella Water Management Plan, review of Water Management Evaluation Tool, interviews, and policy review, the facility failed to follow public health authority recommendations to revise the Water Management Plan in a timely manner and failed to monitor pH levels of water sources. This had the potential to affect all residents. The facility census was 40: Residents Affected - Many Findings include: Review of Legionella Water Management Plan dated [DATE] revealed the facility identified members of the Water Management Team with the exception of naming the Maintenance Director; described the buildings water systems including circulation of water, number of mixing valves and hot water tanks, absence of holding tanks, points of recirculation, and location of tees; and listed the verification process including weekly checks and documentation of pH levels and water temperatures and flushing unused sinks and showers. There were no parameters listed for how long unused sinks and showers were flushed and no parameters for pH and temperature levels. Review of Water Management Evaluation Tool dated [DATE] revealed Bureau of Infections Disease (BID) Specialist #50 assessed the facility's Water Management Program (WMP) and provided 37 comments with recommendations for improvements: • It was unclear whether the facility had recirculation loops or circulatory pumps. • It was unclear what types of water system components/devices were present (shower wands, hoses, bathtubs, drinking fountains). • The WMP did not identify which team members were responsible for implementing the WMP and direct corrective action as needed; maintaining working knowledge of the facility water system(s); identifying system control locations and control limits; and monitoring and documenting program performance. • The WMP did not provide any information regarding description of the type of piping material, age, Page 1 of 3 365187 365187 02/27/2025 Xenia Health and Rehab 126 Wilson Drive Xenia, OH 45385

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many cold water storage; the number and location of cold-water outlets in the facility; or identification of any flow restrictors, aerators, showerheads, wand attachments, drinking fountains, etc. • The WMP did not provide any information which indicated if hot water was recirculated nor was there a description of the type of piping material, age; type and extent of any insulation used to help maintain temperature; the number of hot water outlets and location of any thermal mixing valves within the facility. • Water conditioning equipment is not identified. • The WMP mentions that sinks and showers could have stagnation but does not mention why (vacancies) or identify any of the other items mentioned including dead legs in water piping; wings or rooms that are vacant temporarily unused or have been repurposed, and/or areas with variable temperature; or disinfectant level indicating increased water age. • The WMP did not identify areas with consistently low or no residual disinfectant. • The WMP did not specify control point locations; parameter to be measured (e.g., temperature, pH, disinfectant level); and acceptable level or range of each parameter. • The WMP did not specify control limits (quantitative or qualitative) for each control location • The WMP did not contain information about legionella monitoring including frequency of tests; indicate what events, in addition to routine testing, trigger additional testing (e.g., water service disruptions, before returning unoccupied areas to service, associated cases of legionellosis); or contain context for interpreting results both from the percentage of positive samples found, location(s) of Legionella detection, the quantified number of Legionella in each sample, the trends over time, and the type of Legionella detected. • The WMP is not embodied in a written document that provides all the key elements of the program in a clear and concise manner so that it can be communicated and followed by WMP team. Review of weekly monitoring sheets titled, Logbook Documentation: Testing and Monitoring of Water 365187 Page 2 of 3 365187 02/27/2025 Xenia Health and Rehab 126 Wilson Drive Xenia, OH 45385

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Management Plan for Legionella, dated [DATE] to [DATE] revealed the facility did not document pH levels of water samples. During an interview on [DATE] at 12:16 P.M. Maintenance Director #51 state the facility's Water Management Plan included weekly monitoring of water pH levels and verified there was no documentation of pH levels from weekly monitoring. During an interview on [DATE] at 2:43 P.M. the Administrator stated she received an email [DATE] from the local health department with attachments. The Administrator acknowledged one of the attachments included the Water Management Evaluation Tool from the Bureau of Infectious Diseases dated [DATE] recommending changes; however, she did not open the attachment and was unaware of the recommendations. The Administrator stated she was unaware the recommendations were requirements and not merely suggestions for improvement and stated she believed since the local health department had lifted water restrictions in [DATE], there was no urgency to revise the plan. This deficiency represents non-compliance investigated under Complaint Number OH00162813. 365187 Page 3 of 3