07/10/2025
Survey Tip of the Week: Water Management Assessment
A recent Immediate Jeopardy (IJ) citation in an Ohio nursing facility underscores the importance of maintaining a responsive and up-to-date water management program. While the IJ was the result of multiple failures related to the facility’s infection prevention and water management practices, one notable issue was the facility’s failure to reassess risk after a change in water usage on a particular unit. When the area experienced reduced occupancy, the resulting stagnation risk was not addressed, and no updates were made to the water management plan or related control measures.
According to the CMS State Operations Manual Appendix PP, under F880, “Facilities must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program.” This program must be based on nationally accepted standards—such as those from ASHRAE, CDC, or the EPA, and must include two key elements:
- An assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread.
- Measures to prevent the growth of these pathogens, and how to monitor them.
A facility’s risk assessment should reflect how its water system is actually being used. When occupancy patterns change, whether due to renovation, repurposing of rooms, or census shifts, those changes may alter water flow and increase the potential for stagnation. Without adjusting the assessment and plan to account for these changes, facilities may miss key risks that compromise resident safety.
The full context of this citation and others was reviewed during the July 9, Survey Tips and Tactics call. The CDC’s Water Management Toolkit offers helpful guidance, including a case example of an unoccupied floor. In that case, appropriate control measures were implemented to reduce the risk of Legionella growth, such as flushing unused fixtures and monitoring water temperatures and disinfectant levels. The toolkit emphasizes that assessments and controls should not be static; they must evolve with the facility’s operations.
LeadingAge Ohio encourages facilities to monitor compliance using the surveyor guidance found in the State Operations Manual Appendix PP . Additionally, the survey pathways can be found in the Survey Resources zip file on the CMS Nursing Home webpage and under the downloads section on this CMS webpage. LeadingAge Ohio has provided survey tips to help navigate the changes in the revised QSO-25-14- NH memo. The previously provided survey tips can be accessed on the LeadingAge Ohio webpage under the Communications tab, then The Source tab. CMS has updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo. LeadingAge has developed webinars and resources on the requirements of participation which are located on the LeadingAge learning hub. LeadingAge continues to add QuickCasts on the regulatory groups. Updated resources have also been added on the Nursing Home RoP Tools and Resources webpage.
For more information about the requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the August 13 call at 11:00AM. LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you would like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.
