The nursing home knew about the contamination for months but never implemented required safety measures, never reported the outbreak to state health officials, and never informed the medical director that residents were drinking and bathing in contaminated water.
Federal inspectors found the facility in immediate jeopardy — the most serious violation level — for infection control failures that put all 214 residents at risk of serious injury or death.
The crisis began when water samples taken in late 2024 revealed Legionella bacteria in seven of 10 locations throughout the building. The contaminated sites included bathroom sinks in resident rooms on South Three, South Two, North Two, and other units, plus the North Unit shower and Main Hall sink.
Follow-up testing weeks later found five of 10 samples still positive — a 50% contamination rate that should have triggered immediate emergency protocols.
The facility's own policy required "short-term control measures" and immediate notification to the New York State Department of Health whenever more than 30% of water samples tested positive for Legionella. Instead, administrators did nothing for 43 days.
"There was no documented evidence that a chlorine flush of the domestic water system or other short-term control measures had been performed," inspectors wrote.
The Director of Maintenance told inspectors he informed the Administrator about the positive results and was "taking care of it." He claimed to have performed high chlorine flushes and sanitized shower heads, but could provide no documentation.
Meanwhile, residents continued using the contaminated water system daily.
The Medical Director learned about the contamination only when federal inspectors called during their investigation. "They were not aware water samples at the facility were positive for Legionella," inspectors documented. The doctor said "they would be concerned for the residents and should have been notified."
The Director of Nursing also remained in the dark. When inspectors interviewed her, she "had not been notified that the facility's water system had tested positive for Legionella." She told investigators it would have been crucial to know so medical providers could order proper tests for any resident with pneumonia.
The facility's surveillance policy specifically required investigating all pneumonia cases occurring more than 48 hours after admission for possible Legionnaires' disease. The policy mandated both urine antigen testing and respiratory cultures.
None of the seven pneumonia patients received either test.
Three residents who developed pneumonia died during this period. They had lived on North One, South Three, and another unit — areas where water samples had tested positive for Legionella.
The Administrator told inspectors "there were no Legionnaires' disease testing results for the seven residents diagnosed with pneumonia."
Inspectors also discovered the facility lacked a certified Infection Preventionist, a required position for monitoring disease outbreaks. The previous Infection Preventionist had resigned a month before the inspection, and the position remained vacant.
The facility's Quality Assurance committee, responsible for overseeing safety issues, had been meeting monthly but without required members. Meeting attendance records from October 2024 through February 2025 showed the Infection Preventionist attended zero meetings. The Medical Director missed meetings in January and February 2025.
The Administrator acknowledged the Medical Director "had not come to any meetings since they were only in the facility on Thursdays."
Beyond the Legionella crisis, inspectors found widespread infection control violations during routine care observations.
Resident #82 was on enhanced barrier precautions due to multidrug-resistant organisms, but staff provided care without proper protective equipment. Inspectors watched as workers failed to change gloves or wash hands after incontinence care before touching environmental objects. The resident's catheter drainage bag sat directly on the floor without any barrier.
Staff caring for Resident #148 similarly failed to change gloves or perform hand hygiene after incontinence care before touching other surfaces.
Resident #459 had a nephrostomy tube draining urine directly from the kidney through the skin — a high-risk procedure requiring strict infection control. The resident was supposed to be on enhanced barrier precautions but wasn't, and staff provided hands-on care without appropriate protective equipment.
The Regional Director of Nursing told inspectors "there was no corporate Infection Preventionist to manage the facility's infection control program."
The facility's mission statement promised to "provide exceptional clinical care coupled with a luxury experience for their residents and their loved ones." The Quality Assurance plan committed to "take a proactive approach to improve the quality of life and quality of care of all residents."
Federal inspectors determined the facility corrected its immediate jeopardy violations by early April 2025, after implementing emergency measures including proper Legionella testing protocols and water system monitoring.
During a follow-up visit, inspectors confirmed the facility had finally reported the prior contamination to the state health department, installed functioning disinfection equipment, and begun testing pneumonia patients for Legionnaires' disease. Two recent pneumonia cases tested negative for the disease.
Water samples taken in April showed contamination had dropped to 20% — still above acceptable levels but below the 30% threshold requiring emergency action.
The facility now flushes its water system monthly, sanitizes shower heads monthly, and monitors chlorine levels daily. Staff received education about Legionella testing procedures, with the Administrator, Director of Nursing, Medical Director, and other key personnel signing attendance sheets.
But for the families of the three residents who died from pneumonia during the contamination period, the corrective actions came too late. They will never know whether their loved ones might have survived with proper testing and treatment for Legionnaires' disease.
The deaths occurred in rooms where residents had been exposed to contaminated water for months while administrators failed to follow their own safety policies or notify medical staff of the danger.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waterview Heights Rehabilitation and Nursing Cente from 2025-05-09 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Waterview Heights Rehabilitation and Nursing Cente
- Browse all NY nursing home inspections