**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's documents, policies, and procedure, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the total census of 99 residents. On [DATE], the Local Health Department (LHD) informed the facility that Resident (R) 121 had been diagnosed with Legionnaire's disease while in the hospital. Testing conducted by a third-party water specialist revealed positive areas for legionella in the facility. On [DATE] uncontrolled levels of growth were identified in the hot shower of room [ROOM NUMBER] and in the cooling tower. Before this incident, there was no written water management program in place, and the facility was not actively flushing dead legs (an area of piping system where fluid flow was minimal or nonexistent) in the water system. The resident passed away at the hospital on [DATE]. Additionally, observation on [DATE] of Registered Nurse (RN) 3 revealed she failed to clean and disinfect a glucometer according to the facility's policy, the manufacturer's instructions, and the recommended dwell time for the sanitizing wipe.Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR 483.80 Infection Control, F-880 at a Scope and Severity (S/S) of an L. The facility's Administrator was notified of the IJ on [DATE].The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency (SSA) determined the IJ had been removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a S/S of an F. The findings include:Review of the Centers for Disease Control and Prevention (CDC) document Clinical Guidance for Legionella Infections, dated [DATE], revealed minimizing Legionella growth in complex building water systems and devices was key to preventing infection. The CDC recommended healthcare facilities develop and implement comprehensive water management programs (WMPs). Review of the facility's policy titled, Infection Prevention and Control Program, revised [DATE], revealed the facility created and maintained an infection prevention and control program. Per the policy, the Infection Prevention and Control Program [IPCP] was designed to prevent the development and transmission of communicable diseases and infections, in accordance with national standards and guidelines.Review of the facility's policy titled, Legionella Surveillance, revised [DATE], revealed the facility would establish primary surveillance (approaches to prevent and control legionella infections with no identified cases). The primary surveillance strategies included routine maintenance of the cooling towers; however, the policy did not address routine flushing of empty rooms. According to the policy, legionella surveillance was one component of the facility's water management plan for reducing the risk of legionella and other opportunistic pathogens in the facility's water system. Review of sign-in sheets for staff education titled, Legionella Awareness and Prevention, dated [DATE], revealed staff was responsible for helping to prevent Legionella by following the facility water management plan and regularly running water at sinks and showers in low-use rooms.1. Review of an admission Record, found in R121's Electronic Medical Record (EMR), revealed the facility admitted Resident (R) 121 on [DATE], with diagnoses to include unspecified cerebrovascular disease with aphasia, type 2 diabetes mellitus, and occlusion and stenosis of left carotid artery.Review of R121's hospital records revealed the resident was admitted to the local hospital on [DATE], with diagnoses to include atrial fibrillation with rapid ventricular response, congestive heart failure, and acute respiratory failure with hypoxia. The resident's vital signs included a blood pressure reading of 80/70 millimeters of mercury (mm/Hg), temperature of 100.4 degrees Fahrenheit, and a peripheral capillary oxygen saturation (SpO2) of 87 percent. A chest radiography, dated [DATE], revealed right peripheral infiltrate, suspect pneumonia. A urine antigen test, dated [DATE], was positive for legionella.Review of the entry Minimum Data Set [MDS], found in R121's EMR with an assessment review date (ARD) of [DATE], revealed staff did not assess R121's long- and short-term memory. The resident could not complete the Brief Interview for Mental Status [BIMS] and was documented as 99. Review of the Care Plan Report, found in R121's EMR and dated [DATE], revealed R121 was care planned to discharge from the facility to the community/private residence after skilled nursing services concluded. Additionally, the resident was care planned to be resuscitated in the event of cardiac arrest.Review of the hospital's Critical Care Consult Note, dated [DATE] to [DATE], revealed R121 was admitted to the intensive care unit (ICU) on [DATE] with diagnoses that included atrial fibrillation, acute hypoxic respiratory failure, and pneumonia complicated by sepsis and septic shock. According to the physician's notes, critical care was necessary because one or more vital organ systems were impaired, leading to a high probability of imminent or life-threatening deterioration in R121's condition. According to the notes, R121 was critically ill with overwhelming infection. The resident transitioned to a do not resuscitate (DNR) code status on [DATE], and R121 expired on [DATE]. Further review of hospital records revealed R121's chest radiograph, dated [DATE], revealed the resident had right perihilar infiltrate, suspect of pneumonia, and R121's urine antigen test, dated [DATE], revealed the resident had tested positive for Legionella.During an interview with the Administrator on [DATE] at 4:34 PM, she stated that prior to [DATE] the facility did not have a WMP in place. She stated a plan was developed by the third-party contractor in late [DATE].During an interview with the Director of the Local Health Department (LHD) on [DATE] at 4:17 PM, he stated the LHD was contacted by the local hospital regarding R121, who had tested positive for Legionnaire's disease on [DATE]. The Director stated, We reached out to the facility on [DATE] to inform them of the positive findings. When asked about where R121 might have contracted the disease, he said, He could have been exposed at the facility, adding, I definitely wouldn't rule that out. The LHD did not identify any other potential exposures for R121. He stated the cooling tower could be a potential source, as it had shown positive results for legionella for the longest duration. He further explained that the mist from the cooling tower was released outside, creating a situation where staff and residents coming and going from the facility would have been exposed. He stated, under certain weather conditions, wind could carry aerosols, which could lead to exposure just by persons being in the vicinity of the cooling tower. During an interview with the Infection Preventionist (IP) on [DATE] at 3:00 PM, she stated when the resident was sent to the local hospital's emergency room, he exhibited no respiratory issues; his primary concern was hypertension. The IP stated the facility did not diagnose him with pneumonia and noted the onset of symptoms was rapid. She stated the resident had been admitted to the facility from a local hospital and had only been at the facility for about a week. She stated on day four or five of his stay, he experienced a change in condition, presenting symptoms that included low blood pressure, an increased heart rate, and oxygen saturation levels that dropped to 87 percent. She stated the facility transferred the resident to the local hospital on [DATE], and the local health department informed the facility that R121 had been diagnosed with Legionnaires' disease. She stated the health department also conducted a legionella risk assessment, which found the acidity (pH) and chlorine levels of the facility's water were not within normal limits. During continued interview on [DATE] at 3:00 PM, the IP stated, on [DATE], the facility hired a third-party contractor specializing in water testing to conduct facility-wide testing to identify any potential sources of Legionella bacteria within the facility. She stated the testing confirmed that the cooling tower and the hot shower in room [ROOM NUMBER] tested positive for legionella pneumophila serogroup 1 (strain that causes Legionnaire's disease). The IP stated, on [DATE], the facility conducted a video call with the local health department and a third-party contractor to discuss the results of testing. During the call, she stated, the facility received specific protocols to follow, which included guidelines for flushing procedures. She stated as part of the local health department guidelines she was trained on legionella through video instruction. She stated staff received general infection control, not just Legionella specific training annually and quarterly. She stated the last training specific to Legionella was in [DATE]. When asked by the State Survey Agency (SSA) Surveyor as to what environmental controls the facility had in place to prevent the growth of Legionella before [DATE], she stated that prior to the local health department performing a Legionella Environmental Assessment Form (LEAF) assessment for the facility on [DATE], the facility did not have a water management program (WMP) in place and had not completed the CDC's LEAF assessment. She stated maintenance was testing water temperatures, but she did not know if water flushing protocols were in place. During an interview with the Certified Legionella Expert (CLE) on [DATE] at 8:48 AM, he stated the facility hired his company to investigate sources of Legionella. The CLE stated that he wrote the WMP, including a schematic of the water flow, for the facility in [DATE]. He stated the facility did not have a WMP in place when he was brought in as a consultant. He stated he continued to provide consultation and water testing services. He stated he was a member of the facility's WMP team. Per the interview, he said he conducted water temperature checks and tested the facility's water every two weeks. In addition to the WMP, the CLE stated he conducted a LEAF assessment, which the CDC provided to help facilities gain a comprehensive understanding of their water systems and aerosolizing devices, assisting them in minimizing the risk of Legionnaires' disease. Additionally, the CLE stated samples taken on [DATE], resulted in two positive findings of legionella pneumophila in the hot shower head of room [ROOM NUMBER] and in the cooling tower. He stated the hot shower in room [ROOM NUMBER] tested at 66 colony-forming units (CFUs), while the cooling tower tested at 1500 CFUs, which indicated uncontrolled legionella growth. The CLE stated while the cooling tower was being treated, two further treatments were required for proper remediation. According to the CLE, the latest testing, conducted on [DATE], showed negative results for Legionella pneumophila.During an interview with the Maintenance Director on [DATE] at 5:16 PM, he stated prior to the local health department informing the facility about a positive case of Legionella, there was no active water management plan (WMP) in place. He stated the facility hired a third-party contractor who provided a WMP in [DATE]. Additionally, the Maintenance Director stated staff began flushing empty rooms after [DATE], and the maintenance department continued to flush water in empty rooms.During an additional interview with the IP on [DATE] at 10:10 AM, she stated the Legionella education in [DATE] consisted of slides and verbal education provided during a staff meeting. She stated no written tests were provided to gauge staff comprehension. However, she stated she had provided questions for group discussion.During an interview with Registered Nurse (RN) 6 on [DATE] at 9:28 AM, he stated he provided education to staff regarding Legionella, including its symptoms, in [DATE]. RN6 stated the IP and the Administrator educated him on the topic. He stated he was unsure when staff had received education specific to Legionella prior to 2025. During an interview with the Director of Nursing (DON) on [DATE] at 2:10 PM, he stated the WMP was on the Quality Assurance and Performance Improvement (QAPI) Committee's agenda, but he had not had direct involvement with the WMP team. He stated the QAPI Committee met today for an ad-hoc meeting to discuss the latest Legionella test results. During an interview with the Administrator on [DATE] at 3:08 PM, she stated she was concerned about the detection of Legionella in room [ROOM NUMBER] and in the cooling tower, and once the facility was notified by the local health department, they hired a third-party contractor to assist with testing and to create a WMP. The Administrator stated after the WMP was fully implemented, in-house staff was assigned specific responsibilities to monitor water temperatures, flush unused lines, and maintain the cooling tower. She stated that adhering to infection control policies and guidelines was important for ensuring the safety and well-being of residents, staff, and visitors.During a telephone interview with the Medical Director on [DATE] at 2:59 PM, she stated she regularly attended QAPI meetings to address water quality. She stated it was her expectation that staff followed CDC guidelines and facility policies to prevent infections. The Medical Director stated the importance of infection control was to ensure the residents' health and safety.Review of the facility policy titled, Blood Glucose Monitoring, dated 11/2024, revealed nurses were required to adhere to infection control practices to include cleaning and disinfection of the glucometer according to the manufacturer's instructions. Review of the facility's procedure titled, Blood Glucose Monitoring Device Disinfection, reviewed [DATE], revealed blood glucose monitoring devices would be disinfected according to the manufacturer's recommendations between uses. However, the procedure did not address the manufacturer's sanitation wipe recommendations for dwell time.2. Observation and interview on [DATE] at 6:35 AM on the Maple Unit revealed RN3 approached the nurses' desk and placed a contaminated glucometer down without using a barrier cloth to prevent contamination. She then took out a disinfectant wipe, cleaned the glucometer for approximately 30-seconds, and set it back down on the nurse's desk without placing it on a barrier cloth. When asked about the process for cleaning and disinfecting the glucometer, she stated she used a disinfectant wipe to clean it and then let it dry before putting it back in the medication cart. RN3 showed the SSA Surveyor a bleach wipe that had a three-minute kill time. However, when asked what kill time or dwell time meant, she was unable to answer. RN3 stated she did not realize the glucometer needed to remain wet for the entire three minutes to ensure proper disinfection. Additionally, she stated she was unaware she should place the glucometer on a barrier cloth to prevent cross-contamination. RN3 stated the glucometer was shared equipment and was available for any resident who required fingerstick testing for glucose. RN3 stated following IPCP guidelines was important to prevent disease and the spread of infection. During an interview with the Staff Educator (SE) on [DATE] at 2:10 PM, she stated nursing staff was educated to properly clean and disinfect the blood glucose monitors according to manufacturer's instructions and according to the disinfectant wipe dwell-time. She stated staff was instructed to wipe the glucometer after each resident tested, ensuring that it was thoroughly wiped down, and then allow it to dry in place. She stated the equipment should be placed on a barrier cloth to prevent contamination and the spread of blood-borne pathogens. During an interview with the Director of Nursing (DON) on [DATE] at 2:10 PM, he stated that following the guidelines of the IPCP was a team effort. He stated it was his expectation for nursing staff to properly clean and disinfect the blood glucose monitors according to manufacturer's instructions and according to the disinfectant wipe dwell-time. The DON stated that was important to prevent the spread of blood-borne pathogens. During an interview with the Administrator on [DATE] at 3:08 PM, she stated it was her expectation that staff followed the facility's infection control policies to prevent the spread of infection to residents and staff.The facility provided their Immediate Jeopardy (IJ) Removal Plan on [DATE] verbatim:1. Corrective Action for Residents Affected: All residents with symptoms of pneumonia were tested via urine antigen test for Legionnaires' disease initiated [DATE]. No positive cases were identified at the time of testing. Out of an abundance of caution, the resident in room [ROOM NUMBER] Assisted Living was relocated to room [ROOM NUMBER] Assisted Living on [DATE] related to a positive test result in the shower head in room [ROOM NUMBER] (See Exhibit A). Urine Antigen Test done and Respiratory Monitoring put into place (See Exhibit B). Water outlets in room [ROOM NUMBER] were flushed, and the showerhead was replaced on [DATE] (See Exhibit C).2. Identification of Others at Risk: A comprehensive risk assessment was completed by the Northern Kentucky Health Department to identify all residents, staff, and visitors potentially exposed on [DATE] (Exhibit D). Water samples were collected from all facility wings to determine the scope of contamination on [DATE] by Legionella Control Systems, Inc. (Exhibit E). Residents, families, and staff were notified and educated about signs, symptoms, and transmission risks of Legionella on [DATE] (Exhibit F).3. Systemic Changes to Prevent Reoccurrence: [DATE] -A Legionella Environmental Assessment Form (LEAF) Assessment was conducted in partnership with the Northern Kentucky Health Department. [DATE] - The facility's Infection Preventionist completed additional training on Legionella guidance (Exhibit 0). [DATE] - Flushing protocols were implemented facility-wide and are documented and monitored. (Exhibit I). A Legionella Surveillance Log was established and will be monitored by Infection Preventionist (Exhibit Z). [DATE] - Site visit conducted by Legionella Control Systems; Risk Assessment, Engineering Report, and on-site water testing performed (Exhibit G). [DATE] - Video Call with Legionella Control Systems to go over findings (Exhibit H). [DATE] - Positive Results Bl 158 Hot Shower and Cooling Tower. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit E). [DATE]-Notified ChemSearch of the need for inspection and evaluation of water safety procedures. [DATE] - ChemSearch added Bio-Xile and Chlorine Pellets to cooling tower (Exhibit J). [DATE] - Testing repeated (Exhibit K). [DATE] - 12 month Surveillance Legionella started per Northern Kentucky Health Department. [DATE] - Staff Development provided education to staff including Legionella (Exhibit S). [DATE] - Staff Development continued education (Exhibit S). [DATE] - COO sent out message to staff, residents, families about Legionnaires' Disease (Exhibit Y). [DATE] - Reported to Office of Inspector General via telephone. [DATE] - Positive Results Mech Room Tower. Relevant parties informed (Exhibit K). [DATE] - Corporate Maintenance contacted OBR Cooling Towers (OBR) to schedule a cleaning and sanitization of the cooling tower. [DATE] -Notified Solid Blend, a certified water management company, for consultation and services. [DATE] - Shower Head disinfecting put in place. Started by maintenance [DATE], completed [DATE]. To be done every 6 months (Exhibit M). [DATE] - Solid Blend conducted a separate LEAF assessment and sampled water (Exhibit N). [DATE] - Kentucky Health Department came to facility to discuss risk assessment with Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer. [DATE] - LEAF Assessment Final Report shared Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer. (Exhibit N and H). [DATE] - Positive Result Cooling Tower Basin. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit Q). [DATE] - ChemSearch adjusted chemicals in cooling tower; chemical treatment changed to daily (Exhibit R). [DATE] - Water testing (Exhibit T). [DATE] - Building Maintenance added Float Chlorine to cooling tower. [DATE]-Positive Results Cooling Tower Basin. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit T). [DATE] - Disinfectant concentration monitoring (Maintenance). [DATE] - Water testing (Exhibit U). [DATE] - Water management team reported to QAA committee. Committee members include the Medical Director, Administrator, Infection Preventionist, Social Services, Environmental Services Director, Building Maintanance [sic], Director of Nursing. Also present was Chief Operating Officer. [DATE] - Bioxide Added (Maintenance). [DATE] - Positive Results Water Tower. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit U). [DATE] - Call out to ChemSearch. [DATE] - Water Testing (Exhibit V). 7/!5 [sic]/2025 -Negative Results. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit V). [DATE] - Water Testing (Exhibit W). [DATE] - Water Management Plan Completed. [DATE] - Negative Results Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit W). [DATE] - Water Testing (Exhibit X). [DATE] - Negative Results Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit X). [DATE] -Ad Hoc QAPI meeting held with QAA committee to discuss Water Sample results and Timeline.4. Date of Compliance:IJ removal by: [DATE]