Deep Creek Health & Rehab: Legionella Program Abandoned - VA
He is the Maintenance Director. He has held that title for approximately two years. In that time, no testing has been performed to check for Legionella or any other waterborne pathogen in the facility's water supply. He has not documented the temperature checks he says he performs. He has no diagram of the building's plumbing. He has no list of which fixtures, tanks, or water sources might pose a risk to the 89 residents living inside.
He acknowledged all of this to inspectors on September 19, 2025.
The facility had a water management program once. A written policy, last revised in July 2017, described it in detail: an interdisciplinary team, a diagram of the entire water system, regular identification of areas where Legionella could grow, monitoring of showerheads, water heaters, storage tanks, ice machines, humidifiers, and any equipment where water could stagnate or temperatures could fluctuate. The policy named construction activity, water main breaks, and changes in municipal water quality as situations requiring attention. It committed the facility to documentation.
None of that was happening.
When inspectors asked the current administrator how this had come to pass, the answer was specific and startling. A previous administrator had shut the water management program down. The reason: the facility had turned off the decorative water fountain in the front lobby.
That was apparently the entire rationale. The fountain was gone, so the program was gone.
The former interim administrator, also interviewed that afternoon, confirmed it. He told inspectors the facility had previously maintained a water management program, but it was discontinued when the fountains were removed. He said that decision was wrong. The program, he said, "should have extended through the entire inside and outside of the facility and included anywhere water could become stagnant."
The Director of Nursing told inspectors she believed water management fell under administration's responsibility. She said she expected the facility to have a functioning plan as part of its infection control program. She did not indicate she had taken steps to verify one existed.
Legionella is a bacterium that thrives in warm, stagnant water. It spreads through aerosolized droplets, the kind produced by showers, faucets, and humidifiers. When inhaled, it can cause Legionnaires' disease, a severe form of pneumonia. Elderly people, particularly those with compromised immune systems or chronic lung conditions, face the highest risk of serious illness and death. Nursing home residents fit that profile almost by definition.
The conditions inspectors identified at Deep Creek, an old building with unknown plumbing, no monitoring, no documentation, and no one with a clear map of where the water goes, are precisely the conditions under which Legionella establishes itself undetected.
The facility's own 2017 policy identified the risks. It named water stagnation, temperature fluctuations, biofilm, sediment, and inadequate disinfection as factors that encourage bacterial growth. It required the facility to know where those risks existed and to control them. Eight years after that policy was written, the Maintenance Director told inspectors he had no idea where the risks were.
CMS rated the harm level as minimal or potential for actual harm, and listed the number of residents affected as many, meaning the deficiency had the potential to affect the entire census of 89 people.
No resident was identified as having contracted Legionnaires' disease. That is not the same as saying no one was harmed, or that no one will be. Legionella infections are frequently misattributed to other causes, particularly in elderly patients whose baseline health is already compromised. Without testing, there is no way to know what is growing in the pipes of an old building whose maintenance director, by his own admission, does not know where those pipes go.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deep Creek Health & Rehabilitation from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
Deep Creek Health & Rehabilitation in CHESAPEAKE, VA was cited for violations during a health inspection on September 19, 2025.
He is the Maintenance Director.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.