**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure personal protective equipment (PPE) was implemented to prevent the spread of Covid19 per guidance by the Centers for Disease Control (CDC), when during a Covid19 outbreak, residents were observed not wearing masks. This had the potential to effect all 30 residents who resided in the facility. Further, the facility's failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This had the potential to effect all 30 resident who resided in the facility to be infected by Legionella. Findings include: During an observation on 12/5/22, at 3:04 p.m., 11 residents and one visitor were playing bingo in the dining room at three tables. Only the visitor was masked. Nursing assistant (NA)-A identified the residents: ---One table had five unmasked residents: R1, R25, R22, R2, R23. ---One table had three residents and one visitor: R18's mask was below nose, R4's mask below mouth, R15 no mask, and visitor was masked. ---One table with three unmasked residents: R179, R19 and R12. During an interview on 12/6/22, at 9:02 a.m., nursing assistant (NA)-B stated residents were asked before they left their rooms if they wanted to wear a mask, adding residents had a right to refuse. Together with NA-B, looked at NA documentation in the electronic medical record (EMR). Every shift, NA's where to document two tasks related to resident masking: 1) Ask resident to apply mask when completing cares and 2) Ask resident to apply mask when leaving their room. NA's were to answer if the task was completed. For the past two weeks, some NA's answered the question yes, and some answered no. NA-B stated no meant the resident declined the mask. NA-B stated some staff maybe did not understand the question and documented no, meaning they did not ask the resident to apply a mask. During an interview on 12/6/22, at 9:03 a.m., (NA)-C stated NA's were to ask residents if they wanted to put on a mask before they left their room, adding, But do we always? No. NA-C stated she did not always remember to ask a resident. NA-C was aware the facility was currently in Covid19 outbreak status. During an interview on 12/6/22, at 9:05 a.m., registered nurse (RN)-D stated staff encouraged residents to put on a mask when done with resident cares and before residents left their room, adding they supplied each resident with a new mask each day. Together looked at the EMR and NA tasks. RN-D verified sometimes the task was completed and sometimes it wasn't. NA-A stated the expectation was that staff would offer a mask to a resident before leaving their room, but some residents would decline and had a right to do so. During an interview on 12/7/22, at 9:28 a.m., R2 (who was cognitively intact per quarterly Minimum Data Set [MDS] assessment dated [DATE]), was sitting in a wheelchair in her room watching TV. R2 stated staff sometimes asked if she wanted to wear a mask, but not always. R2 stated if staff reminded her, she wore a mask .If they don't remind me, I don't remember. R2 stated she was aware of Covid19 and wearing a mask helped prevent catching it. During an interview on 12/7/22, at 9:35 a.m., R25 (who had moderate cognitive impairment per admission MDS dated [DATE]), in her room, stated staff did not ask her if she wanted to wear a mask when she left her room. Looked around for a mask, stating she didn't see one and stated it might be in a drawer somewhere. During an interview and observation on 12/7/22, at 9:37 a.m., observed (NA)-C transport R17 via wheelchair out of her room to the dining room. R17 was not masked. NA-C admitted he did not ask R17 if she wanted to mask before leaving her room, adding, I should have, but I didn't; they almost always say no. Observed R17 and R19 sitting together in the dining room, both unmasked. During an interview on 12/7/22, at 9:47 a.m., R17 (who was cognitively intact per admission MDS dated [DATE]), stated staff did not ask her if she wanted to wear a mask when she left her room. R17 stated she knew she should wear a mask, but it fogged up her glasses if they could find a mask that didn't fog up my glasses, I would [wear one], adding she knew it was important as she used to work in healthcare and wore a mask all the time. During an interview on 12/7/22, at 12:20 p.m., R23 (who had moderate cognitive impairment per quarterly MDS dated [DATE]), in her room watching TV. Stated no one asked if she wanted to wear a mask when she left her room, adding she would wear one if asked, as it was better to err on the side of caution. Observed two masks in R23's room; neither appeared to have been wore, both flat and unwrinkled. During record review of residents observed unmasked in communal areas: --R18, R4, R179, R19, R17: Nothing in care plan about Covid19 and nothing about masking. --R15's care plan dated 5/6/22: Focus of Covid19 was present; nothing about masking. --R12's care plan dated 5/18/20: Focus of Covid19 was present; nothing about masking. During an interview on 12/7/22, at 10:56 a.m., with administrator, RN-D, (RN)-B and SW-A, all verified the Covid19 community transmission rate was high and the facility was in Covid19 outbreak status. Informed of observations of residents not wearing masks. RN-B stated residents were asked to mask before leaving their rooms. RN-D stated most residents chose not to wear a mask. During the same interview, RN-B stated she was responsible for creating and updating care plans and that Covid19 language in care plans was standard. RN-B stated some residents didn't have Covid19 language in their care plans as she had not gotten to some of the newer residents yet. RN-B confirmed the Covid19 language in the care plan did not indicate anything about resident masking; whether they should wear masks or if were unable to tolerate wearing a mask. RN-B acknowledged she was aware during a Covid19 outbreak, everyone should mask in communal areas. The administrator stated residents had been educated about wearing masks, but it had been awhile, and stated there was likely some mask fatigue among residents. The group acknowledged Covid 19 was still a concern and it was important to ensure residents were protected. During an observation on 12/7/22, at 12:10 p.m., observed an unidentified staff member in the dining room asking residents, Do you want to put a mask on? The question did not included rationale for asking. During an interview on 12/7/22, at 1:32 p.m., the administrator stated since meeting earlier, staff had been asking residents if they wanted to wear a mask and residents had been saying no. Informed the administrator that this was observed in the dining room and that the question was asked without telling the resident why and was likely an ineffective way to encourage residents to wear a mask during an outbreak. The administrator was encouraged to consider a reset with residents and staff and reeducate on the rationale for wearing masks. Facility policy titled Source masking for residents, revised date of 3/24/22, indicated the purpose was to minimize the threat of Covid19 transmission. A surgical mask would be provided to all residents daily upon request. Residents would be educated on the use of masks. Resdient's have a right to refuse to wear a mask at any time, even during outbreak status. Water management program Review of website for ASHRAE titled Risk Management For Legionellosis dated 10/15 indicated . The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors. Health-care facility with patient stays over 24 hours. Facilities designated for housing occupants over age [AGE]. The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system Review of the Centers for Disease Control and Prevention (CDC) website titled Legionella. Prevention and Control, dated 03/25/21 indicated .The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella.Key Elements.Seven key elements of a Legionella water management program are to. Establish a water management program team. Describe the building water systems using text and flow diagrams. Identify areas where Legionella could grow and spread. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met . Make sure the program is running as designed (verification) and is effective (validation).Document and communicate all the activities. Principles. In general, the principles of effective water management include.Maintaining water temperatures outside the ideal range for Legionella growth.Preventing water stagnation.Ensuring adequate disinfection.Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella.Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. Review of a document provided by the facility titled Legionella Water Management Program, dated 06/02/17 indicated .It is the policy of Fairview Care Center to prevent an outbreak of Legionnaires Disease through implementation of an effective Legionella Water Management Program.Preventative Maintenance.Faucet aerators will be replaced every two years.Shower heads and nozzles will be replaced every two years.Eyewash stations bottles will be replaced per manufacturer's recommendation/expiration date.Quarterly water samples from 10 risk locations throughout the facility will be tested. Sample must be collected from a temperature range of 50-104 degrees Fahrenheit.Results will be compared to the normal range.Results will be recorded in the Logbook.Positive results require additional testing with 5 business days. Review of a binder provided by the facility titled Water Management Program included facility policies on their water management program, a Legionella testing log which had five testing entries dated 10/21 (there was no year documented). Included was test for Legionnaire's disease dated 03/14/18 which indicated the test results were within acceptable levels. There was a description of the water lines and how the water was processed throughout the facility and then sent out and then sent to the facility's sewer. Included was a hand drawn diagram of the facility's water system. Included was an uncompleted CDC risk assessment for the prevention of Legionella. During an interview on 12/05/22 at 4:29 p.m., the maintenance director-(MD)-A stated he was hired in September of 2019 and was to be trained on how to implement the water testing for Legionella, but this never happened. The MD-A stated the water management program was never fully implemented. MD-A stated he changes the faucets aerators every two years. MD-A stated there had been only one test for Legionnaires completed and that was in 2019. During an interview on 12/05/22 at 7:13 p.m., the director of nursing (DON) stated there had not been any Legionella in the facility for the past three years. During a subsequent interview on 12/06/22 at 8:46 a.m., MD-A stated when he took over the maintenance position he was in the dark about Legionella. MD-A stated the date of the testing logs was 10/21/19 and this was the last time a Legionella test was completed. MD-A confirmed there were no additional testing logs besides the ones from 10/21/19. MD-A stated there has been no annual review of the water management program. MD-A stated he contacted the former Administrator for direction. MD-A stated he planned on reaching out to a company who could develop and perform the requirements for an effective water management program. During an interview on 12/06/22 at 9:23 a.m., MD-A stated the city water utility company completed water testing each week but did not know the results. MD-A stated there has been no integration with the city utility company and the facility's water management program. MD-A stated he did not complete logs of when faucets, shower heads pipes, or the ice machine were maintained. During an interview 12/06/22 10:36 a.m., the DON stated the city water utility company tested for chlorine and fluoride. The DON provided these documents, from the city, for verification. During an interview on 12/06/22 at 11:22 a.m., the Clinical Manager/Infection Control Preventionist (CM/ICP)-B stated she did not get involved in the facility's water management program. CM/ICP-B stated if a resident tested positive for Legionella, she would notify the local health department and receive direction. CM/ICP-B stated she did not get involved with environmental issues and potential outbreaks of Legionella. During an interview on 12/06/22 at 2:50 p.m., the DON confirmed there were 30 residents over the age of 65. DON stated 10 of these residents had respiratory disease and three used a continuous positive airway pressure (CPAP) machine. During an interview on 12/07/22 at 8:26 a.m., the administrator stated her expectation was to have an effective water management program. .