**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 7/24/24 at 10:56 AM, Maintenance Director B was queried on the investigative legionella water sampling on 6/3/24 for room [ROOM NUMBER]. When asked what water fixture the sample came from, Maintenance Director B stated they probably tested the sink of the room [ROOM NUMBER] bathroom. When queried why the shower fixture wasn't tested in addition to the sink, Maintenance Director B stated, Didn't think about it, I guess. When queried about the sampling method, Maintenance Director B stated that they don't have sampling instructions from the lab and that they let the water run for a few minutes, then draw the sample. According to the facility's Water Management Program, it notes on page 26, Informative Annex C - Guidance Legionella Testing is Utilized . Sample Collection Hot Water Systems - Obtain two samples pre flush & post flush: - Pre Flush: Turn hot water on & immediately collect first 250 ml. Sings, showerheads, hoses, bottom of hot water tank. *Do NOT remove the shower head. Post Flush: Allow water to run for 1 full minute or until the water is hot. - Two samples can help determine if contamination is at the fixture or from supply water in the pipes. Resident #205 Review of intake documentation pertaining to Resident #205 detailed the facility had positive legionella in the water for about a year and were not willingly working with the Local Health Department (LHD) as required by public health code. The intake further revealed an individual (Resident #205) tested positive for Legionnaires' (serious type of pneumonia caused by the Legionella bacteria) and was at the facility within the incubation period (time between exposure/infection to symptom onset) of Legionnaires' illness onset. Record review revealed Resident #205 was admitted to the facility on [DATE] with diagnoses which included right ischium (one of three bones that form the hip bone) fracture, falls, non-insulin dependent diabetes mellitus, atrial fibrillation (irregular heart rhythm), and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to moderate assistance to complete Activities of Daily Living (ADL). Resident #205 was transferred to the hospital on 5/31/24 and did not return to the facility. A review of the facility provided Resident Infection Line Listing 2024 was completed. Resident #205 was included on the line list as having a Respiratory Tract infection caused by Legionella/Influenza with an onset date for the infection listed as 5/31/24. Review of Resident #205's Electronic Medical Record (EMR) revealed the following documentation: - 5/31/24 at 3:46 PM: SBAR Communication Form and Progress Note . 1. The change in condition, symptoms, or signs . unresponsive vitals WNL (Within Normal Limits) . 2. This started on: 5/31/24 . 3. Since this started has it has . Stayed the same . 4. Things that make the condition or symptom worse are: dyspnea (shortness of breath) . Vital Signs . Most Recent O2 sats . 90 (%) Date: 5/30/24 (at) 21:59 . Room Air . Mental Status Changes . Decreased consciousness . Most Recent Blood Glucose . 127 . Date: 5/31/24 (at) 10:47 AM . - 5/31/24 at 4:05 PM: Change of Condition . 1. List symptoms present related to the change of condition . COG (sic- unknown abbreviation) responsive with vitals WNL (Within Normal Limits), no response to pain . (Family) present in facility at time of change . - 5/31/24: Health Care Provider Note: Notified by DON that patient became unresponsive, glucagon (medication used to treat low blood sugar) administered, BS (Blood Sugar) increased, and patient stabilized. New orders given for patient to be sent to the emergency department for further evaluation and treatment . Addendum Details: Patient still unresponsive, sent out . Addendum Created Date: 5/31/24 at 4:17 PM. Review of Resident #205's Skilled Daily-Medically Complex Nursing documentation from 5/23/24 to 5/31/24 revealed the following: - 5/23/24 at 3:31 AM: Resident #205 was Alert and Orientated to person, place, date, and time (A & O X 4), experiencing shortness of breath, and receiving oxygen therapy while simultaneously specifying the Resident's most recent SPO2 was 98% on room air on 5/21/24 at 9:59 PM. - 5/24/24 at 11:40 PM: Resident #205 was A & O to person, place, and time, experiencing shortness of breath, and receiving oxygen therapy via nasal cannula. Per EMR documentation, Resident #205 had a planned discharge home for the facility in place for 6/3/24. Review revealed the last documented SPO2 vital sign documentation in Resident #205's EMR occurred on 5/30/24 at 9:59 PM and specified, 90% . Room Air. Review of Resident #205's Health Care Provider orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2024 revealed the Resident did not have a task in place for Legionella and/or respiratory infection sign/symptom monitoring. Further review of scanned documentation in Resident #205's EMR revealed a fax from the hospital to the facility dated 6/3/24. The fax contained Pneumonia Panel sputum testing laboratory testing results. The laboratory test was dated 6/1/24 and specified Resident #205 tested positive for Legionella pneumonia, Coronavirus, Influenza A, and Klebsiella Oxytoca (bacteria commonly found in the intestinal tract, mouth, and nose which can cause opportunistic infections including pneumonia). Review of facility water testing report dated 6/3/24 revealed the facility tested on e source of water in the room Resident #205 resided in while at the facility following the report received from the hospital confirming Resident #205 had Legionella pneumonia. The report did not specify what water source in the room was tested (shower, sink, etc.). An interview was conducted with Resident #205's Family Member Witness G on 7/24/24 at 11:47 AM. When queried regarding Resident #205, Witness G replied, They are home on Hospice now. When queried regarding the reason Resident #205 was admitted to Hospice, Witness G stated, (Resident #205's) lungs never recovered. Witness G was asked what they meant and explained the Resident was transferred from the facility to the hospital where they were intubated and required mechanical ventilation (machine which assists and/or breaths for an individual) because of how ill they were. Witness G stated the Resident was diagnosed with Legionella pneumonia, Covid-19, and influenza and never fully recovered. Witness G continued, The (Local) Health Department contacted me about Resident #205 being diagnosed with Legionella. When asked who contacted them from the Health Department, Witness G replied (Registered Nurse (RN) O) and indicated they had maintained in communication with them. When queried regarding Resident #205's stay in the facility, Witness G revealed Resident #205 had fallen at home, broke a bone in their hip, and went to the facility for therapy. When queried if Resident #205 had gotten sick while at the facility, Witness G verbalized they had and revealed they were there when Resident #205 was transferred to the emergency room (ER). Witness G stated, The night before (Resident #205 was sent to the hospital), they were complaining of having a hard time breathing. Witness G continued, Their SPO2 (measurement of percent of oxygen in blood) was in the 80's (%) (normal is greater than 92%). When asked if the facility staff obtained the Resident's SPO2 measurement, Witness G confirmed they and revealed they were unaware that an SPO2 in the 80's was low until informed by the nurse in the hospital. When queried what the facility nursing staff did in response to Resident #205's complaints of difficulty breathing and decreased SPO2, Witness G stated, They put them in bed. Witness G was asked if the Resident was receiving supplement oxygen at that time, and replied they could not recall. When asked if Resident #205's breathing and SPO2 improved after they were assisted back to bed by staff, Witness G revealed they left the facility to let Resident #705 rest. Witness G disclosed their sister went to see Resident #205 the following morning and called them to come to the facility because they were concerned something was wrong. Witness G indicated they went to the facility immediately and stated, (Resident #205) was very lethargic and acting funny. When asked how the Resident was acting funny, Witness G revealed they were not acting normally and would not eat or drink. When asked, Witness G specified they as well as their sister had verbalized their concerns regarding the Resident to facility nursing staff. Witness G stated, A few nurses came in and then left. When asked what the staff said when they left, Witness G indicated they did not really say anything and didn't come back soon. Witness G emphasized it took a long time for the facility nursing staff to return. Witness G was unable to recall the names of the nursing staff when asked. When queried what occurred when the nursing staff did return, Witness G replied, Took (Resident #205's) blood sugar. It was in the 70's (normal value prior to eating is 80-130 milligram [mg]/decaliter [dL]). Witness G verbalized Resident #205 was diabetic and they thought a blood glucose level in the 70's was good and did not think it would cause the Resident #205's symptoms. Witness G stated, They (facility nursing staff) said it could be sugar and started pumping (Resident #205) full of stuff. When asked what stuff they were referring to, Witness G replied, Sugar solutions. Witness G verbalized Resident #205 did not improve and was transferred to the hospital. Witness G then stated, We thought we were going to lose (Resident #205). Witness G revealed Resident #205 was intubated (tube placed down the throat into the trachea) and placed on a ventilator (machine which assists and/or breaths for an individual) in the hospital. When queried, Witness G specified Resident #205 was admitted to the Intensive Care Unit (ICU) and had a couple days of testing which resulted in positive Legionella pneumonia, flu, and Covid-19 results. An interview was completed with RN O on 7/24/24 at 12:24 PM. When queried regarding Resident #205, RN O revealed they were notified by (the hospital) that the Resident tested positive for Legionella. When queried regarding their role at the health department, RN O stated, I do the initial investigations for reportable diseases including contact tracing. RN O revealed they contacted Witness G as well as the facility. RN O was asked if they were able to determine if Resident #205 contracted the pathogen at the facility and replied, We use 10 days within our investigations and indicated Resident #205 was at the facility for nine days. RN O stated, (Resident #205) was in the hospital from [DATE] to 5/21/24 prior to being transferred to the facility. When queried regarding the incubation period for Legionella and asked if Resident #205 was within the incubation period to have potentially contracted the bacteria at the facility, RN O stated, (Resident #205) was definitely within the (incubation) timeframe. When queried regarding the facilities response when they contacted them regarding Resident #205's positive legionella test, RN O responded, Never heard back. When queried what they did when they did not hear back, RN O indicated they discussed the case with their colleagues at the Health Department and another staff took over contacting the facility. On 7/24/24 at 10:55 AM, an interview was completed with Maintenance Director B. When queried where the legionella water sample on 6/3/24 was collected from in room [ROOM NUMBER], Director B stated, Probably the sink. When asked if they were certain the sample was collected from the sink, Director B verbalized they were unable to say for sure. When queried if there are other sources of water in the room, Director B confirmed there were. Director B was then asked why they did not test all water sources in the room due to Resident #705 testing positive for Legionella and why other communal water sources were not tested and did not provide an explanation. Resident #203 Record review revealed Resident #203 was most recently admitted to the facility on [DATE] with diagnoses which included right sided hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), diabetes myelitis, and weakness. The MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set up to total assistance to complete ADL. A review of facility provided Resident Infection Line Listing April 2024 revealed Resident #203 was listed as having a Fungal infection involving the Skin, Soft Tissue, and Mucosal with an onset date of 4/8/24 and a resulted date of 4/22/24. Review of Resident #203's EMR documentation revealed decreased SPO2 (oxygen saturation) documentation of 80% on room air on 2/6/24 at 9:59 PM and 88% on room air on 2/7/24 at 1:55 PM. Review of progress note documentation in Resident #203's EMR revealed the Resident was seen by the Health Care Provider on 2/6/23 for an elevated blood pressure reading of 220/46. The note included the SPO2 of 80% under the Vital Signs section of the note but did not address the abnormal low value. A Nurses' Note dated 2/7/24 at 2:46 PM was present in Resident #203's EMR and detailed, (Resident #203) SPO2 88% on RA (Room Air) . placed 3L (liters) NC (nasal cannula) O2 . per order that is already in pt's chart. Order is written to keep . SPO2 above 90% PRN (as needed). Review of Resident #203's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February 2024 revealed the Resident had Legionella Monitoring . until 2/7/24 (Start date: 12/8/23; Discontinued: 2/7/23 at 1:00 PM). Legionella Monitoring for 2/6/24 and 2/7/24 was documented as No indicating Resident #203 had no signs/symptoms of Legionella. Resident #203's February 2024 MAR/TAR also included, Monitor for signs and symptoms respiratory infections and/or decrease in O2 sats (SPO2) . every day and night shift If new s/s present document in progress note and notify physician. There was a checkmark on the MAR/TAR indicating the task had been completed. Resident #203 was not tested for Legionella. Resident #211 Record review revealed Resident #211 was admitted to the facility on [DATE] with diagnoses which included kidney disease and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial to total assistance to complete assistance to complete ADL. Resident #211 was discharged from the facility on 2/9/24. Review of Resident #211's EMR revealed the Resident tested positive for Covid-19 at the facility on 1/29/24. A review of progress note documentation in Resident #211's EMR revealed the Resident had minor congestion, coughing, and rhinorrhea (runny nose) with mild decreased activity on 2/5/24. A review of Resident #211's MAR/TAR for February 2024 received the Resident was receiving Guaifenesin (cough medication/expectorant) every six hours from 1/31/24 until their discharge on [DATE]. The task, Monitor for signs and symptoms respiratory infections (fever . cough . congestion or runny nose .) . every day and night shift If new s/s present document in progress note and notify physician was present on the MAR/TAR for February 2024. All documentation completed indicated the Resident had no signs/symptoms of respirator illness. Resident #211 was not tested for Legionella. Resident #219 Record review revealed Resident #219 was most recently admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), heart failure, and respiratory failure. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set up to supervision assistance for showering/bathing, transferring, and ambulation. Review of Resident #219's EMR revealed the Resident was diagnosed with pneumonia on 1/22/24. Resident #219's progress note documentation in the EMR revealed the Resident had a cough in February 2024. Resident #219 was not tested for Legionella. Resident #221 Record review revealed Resident #221 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, atrial fibrillation (irregular heart rhythm), and anemia. Review of the MDS assessment dated [DATE] revealed Resident #221 was cognitively intact and required set up to total assistance to complete ADL. Resident #221 was discharged from the facility on 3/6/24. Review of Resident #221's EMR revealed the Resident was transferred from the facility to the hospital on 1/2/24 for Possible Covid Pneumonia, Febrile (elevated temperature), Tachycardia (rapid heart rate) which began on 1/1/24. Resident #221 was diagnosed with Covid-19 at the hospital and returned to the facility on 1/15/24. Further review of Resident #221's EMR revealed laboratory testing was completed on 2/28/24 with abnormal results including an increased [NAME] Blood Cell (WBC) count (indicative of infection), elevated neutrophils (a type of WBC that increases during bacterial infections), and elevated monocytes (a type of WBC). A chest X-ray was completed on 2/29/24 which showed atelectasis (collapse) or pneumonia in the left lung base worse in comparison to the x-ray completed on 2/2/24. Review of progress note documentation in Resident #221's EMR revealed a Health Care Provider note dated 3/1/24 specifying the Resident had intermittent shortness of breath for an unidentified amount of time, was diagnosed with Unspecified Bacterial Pneumonia, and was started on antibiotic therapy. Resident #221 was not listed as having a respiratory infection on the Resident Infection Line Listing for February or March 2024. Resident #221 was not tested for Legionella. Resident #227 Record review revealed Resident #227 was originally admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia and hemiparalysis following cerebrovascular accident (stroke), dementia, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial to total assistance to complete ADL with the exception of eating. At 4:00 PM on 7/25/24, Resident #227's room door was open, and they were observed laying in their bed from the hallway. The Resident seen and heard coughing. A sign specifying Contact Precautions was in place outside of the Resident's room door, but Personal Protective Equipment (PPE) was not present outside of the Resident's room door. Resident #227 was noted to have a roommate. An interview was completed with Certified Nursing Assistant (CNA) Q at this time. When queried regarding the Contact Precaution sign in place outside of Resident 227's room, CNA Q revealed Resident #227 did not have Contact Precautions in place and indicated their roommate was in precautions. When queried regarding the location of the PPE and the reason for Contact Precautions, CNA Q indicated PPE was inside the room and they were unsure of the reason that the precautions were in place. When queried if Resident #227 had a cough, CNA Q verbalized the Resident had an occasional cough. On 7/25/24 at 4:10 PM, an interview was completed with Resident #227. When queried how they were feeling, Resident #227 revealed they were more concerned about their roommate. When queried regarding observation of their coughing, Resident #227 confirmed they have had an intermittent cough. When asked how long they had the cough, Resident #227 revealed it was not new but was unable to provide a specific timeframe. Review of Facility provided Resident Infection Line Listing for January to July 2024 revealed Resident #227 was listed as having Covid-19 in January with an Onset Date of 1/2/24. The March and April 2024 including Resident #227 as having Bacterial Conjunctivitis (pink eye) with an onset date of 3/20/24. Resident #227 was also included on the April and May 2024 line listings for a Urinary Tract Infection (UTI) with an onset date of 4/26/24. The line listings did not include any signs/symptoms of infections, such a cough, which had not been treated with an antimicrobial medication. Resident #227 was not tested for Legionella. Resident #229 Record review revealed Resident #229 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease with dialysis dependence, liver cirrhosis, COPD, and heart disease. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to total assistance to complete all ADL with the exception of eating. Resident #229 was discharged to the hospital on 4/1/24 and did not return to the facility. Review of Resident #229's EMR revealed the Resident had a chest x-ray completed on 2/10/24 which showed, Mild patchy left basilar density compatible with pneumonia or atelectasis. In clinical context of cough, fever, elevated WBC or other signs of lung infection, findings would be compatible with pneumonia; otherwise, atelectasis should be considered . Progress note documentation in Resident #229's EMR revealed the Resident complained of fever and a productive cough on 2/14/24, had congestion, cough, and diminished lung sounds on 2/16/24, and diminished lung sounds and difficulty breathing were included in documentation on 2/20/24. Resident #229 was diagnosed with Pneumonia and treated with antibiotics from 2/14/24 to 2/20/24. Resident #229 was not tested for legionella. Resident #231 Record review revealed Resident #231 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included respiratory failure, tracheostomy (surgically created opening in the front of the neck into the trachea to allow for the passage of air into the lungs), and diabetes mellitus. Review of the MDS assessment dated [DATE] revealed Resident #231 was cognitively intact and required set-up to total assistance to complete ADL. Review of progress note documentation in Resident #231's EMR revealed the Resident had a strong, productive cough and was requiring suctioning every two hours with thick/tan secretions on 2/23/24. Resident #231 had a chest x-ray on 3/4/24 which showed Mild right lower lobe pneumonia or atelectasis . Resident #231 was transferred to the hospital on 3/4/23 due to suspected respiratory failure/respiratory infection and did not return to the facility. Resident #231 was not tested for legionella. Resident #235 Record review revealed Resident #235 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis (infection in the bone), diabetes mellitus, end stage kidney disease, and mild cognitive impairment. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set up to maximum assistance to complete ADL with the exception of bed mobility. Review of Resident #235's EMR revealed a chest x-ray was completed on 3/17/24. The results of the x-ray detailed, Subtle patchy opacity is seen in the bilateral lower lungs. This is likely secondary to pulmonary edema (fluid build-up in the lungs), atelectasis and/or pneumonia. Laboratory testing was completed on 3/18/24 which revealed the Resident did not have an elevation in WBC but did have elevated Monocyte and immature granulocyte (may be an early sign of infection) counts. A review of Resident #235's EMR reviewed documentation dated 3/19/24 which revealed the Resident had pneumonia with signs and symptoms which included shortness of breath, cough, increased WBC, productive cough, and a positive chest x-ray. Resident #235 was not tested for Legionella. Resident #237 Record review revealed Resident #237 was originally admitted to the facility on [DATE] with diagnoses which included COPD, atrial fibrillation, and heart failure. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to substantial assistance to complete ADL. A review of facility provided Resident Infection Line Listing June 2024 revealed Resident #237 was treated for pneumonia with an onset date of 6/11/24. Record review revealed Resident #237 was transferred to the hospital from the facility on 6/5/24 due to a change in condition. Resident #237 was diagnosed with pneumonia at the hospital and returned to the facility on 6/11/24. Resident #237 was not tested for Legionella. Resident #239 Record review revealed Resident #239 was admitted to the facility on [DATE] with diagnoses which included heart disease, COPD, diabetes mellitus, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required total assistance to complete ADL. An interview was completed with Resident #239 on 7/25/24 at 4:15 PM. Resident #239 was observed in their room in bed. When queried if they had any signs and symptoms of respiratory infection, Resident #239 stated they had a cough. A review of facility provided Resident Infection Line Listing . revealed Resident #239 was listed as having aspiration pneumonia with an onset date of 4/15/24. A Nurses' note was present in Resident #239's EMR dated 4/13/24 which specified, STAT CXR (chest x-ray) ordered . c/o (complain of) coughing and congestion. Resident #239 was not tested for Legionella. Resident #241 Record review revealed Resident #241 was originally admitted to the facility on [DATE] with diagnoses which included COPD, heart failure, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to maximum assistance with the exception of eating and bed mobility. Review of documentation in Resident #241's EMR revealed a Pertinent Charting-Infections/Signs Symptoms progress note dated 6/14/24 which specified, Late Entry . Lower Resp infection-bronchitis . New onset of cough with sputum production . unclear flow of ideas and confusion . The note indicated antibiotics were ordered. Further review of documentation in Resident #241's EMR revealed the Resident experienced ongoing cough in June 2024 and a change in respiratory status with a decreased SPO2 of 76% on 6/27/24. Resident #241 was not tested for Legionella. Resident #243 Record review revealed Resident #243 was admitted to the facility on [DATE] with diagnoses which included a right pubis fracture, weakness, and chronic pain. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required moderate assistance to complete some ADL. Record review revealed Resident #243 tested positive for Covid-19 on 7/5/24. Resident #243 was not tested for Legionella and was discharged home on 7/16/24. Resident #253 Record review revealed the Resident #253 was originally admitted to the facility on [DATE] with diagnoses which included anemia, weakness, and kidney failure. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to moderate assistance to complete ADL. Resident #253 was discharged from the facility on 7/8/24. Review of Resident #253's EMR revealed the Resident had a sore throat and runny nose which started on 7/2/24 tested positive for Covid-19 on 7/5/24. Resident #253 was not tested for Legionella. Resident #254 Record reviewed Resident #254 was originally admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, COPD, lower extremity cellulitis, and falls. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to substantial assistance to complete ADL. A review of progress note documentation in Resident #254's EMR revealed the Resident had nasal congestion and a cough on 5/30/24. On 6/2/24 at 5:30 AM, Resident #254 was observed pulseless and apneic (not breathing) by staff, required Cardiopulmonary Resuscitation (CPR), and was transferred to the hospital. Resident #254 was not included as having signs/symptoms of respiratory infection on the Resident Infection Line Listing for May or June 2024. Legionella testing was not completed. Resident #256 Record review revealed Resident #256 was originally admitted to the facility on [DATE] with diagnoses which included Hepatitis C, cirrhosis, weakness, seizures, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to total assistance to complete ADL. Review of Resident #256's MAR/TAR for June 2024 revealed the task, Legionella monitoring: Dose the resident have new onset of any of the following symptoms? Headache, muscle aches, fever (>104F), cough, SOB (Shortness of Breath), Chest pain, GI (gastrointestinal) symptoms, Confusion or mental status changes? Two times a day for 14 days . (Start Date: 6/3/24; Discontinued: 6/17/24) with yes or no response charting. A yes response indicating the Resident had signs/symptoms of Legionella was documented on 6/5/24 day shift. Further review revealed Resident #256 had an order for Acetylcysteine (mucolytic medication used to thin mucus in the airway to make it easier to cough and clear the secretions) 600 milligrams (mg) every morning and at bedtime for cough/cold/allergies . Resident #256 was not tested for Legionella. Resident #257 Record review revealed Resident #257 was originally admitted to the facility on [DATE] with diagnoses which included tracheostomy, gastrostomy (surgically created opening through the abdominal wall to the stomach for the introduction of food/nutrition), skull fracture, cerebral edema (brain swelling) traumatic subdural hemorrhage (bleeding and blood collection between the brain and the skull), and seizures. Review of the MDS assessment dated [DATE] revealed the Resident was dependent upon staff for completion of all ADL. A review of Resident #257's EMR revealed progress note documentation specifying the Resident had a frequent, wet productive cough on 6/6/24 and 7/3/24. Resident #257 had laboratory testing completed on 6/27/24 which showed an elevated and upward trending WBC. Resident #257 was not tested for Legionella. Resident #259[TRUNCATED]