Based on record review and interviews, the facility failed to submit the required staffing information based on payroll data in a uniform format by the required deadline. Specifically, the facility failed to submit data for quarter one (October 1, 2024 - December 31, 2024) of the federal fiscal year 2025. Findings include: A review of the facility's Payroll Based Journal (PBJ) report from Center of Medicare Services (CMS) revealed the facility failed to submit data within the required timeline for quarter one of 2025. Review of the facility's document titled CMS Data Submission Report for quarter one of 2025, revealed it did not contain all the components required by CMS, specifically the daily resident census was not included in the report. During an interview conducted with the Administrator on 05/08/25 at 2:28 PM, the Administrator confirmed the PBJ report submitted for quarter one of 2025 did not include the required information of the daily resident census.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility policy, the facility failed to establish and implement a water management program which identified measures to minimize the risk of Legionella in the facility. Findings include: Review of the facility's policy titled Legionnaire's Disease Policy and Procedure, effective date 01/02/20 revealed, Legionnaires' disease is a serious pneumonia caused by the Legionella bacteria. It is not contagious and is typically contracted by inhaling contaminated water droplets, often from contaminated sources like cooling towers or water systems in buildings. Symptoms can include fever, cough, chills, muscle aches, and headaches, similar to the flu . To test for Legionella in a nursing home, start with a risk assessment to identify high-risk areas. Then, create a sampling plan, collect water samples from identified sites, and analyze them in a lab. Finally, implement a water management plan to control Legionella growth and spread, including regular testing and corrective actions . 1. Establish a WMP team (Infection control Team). 2. Describe the building water systems. 3. Identify areas where Legionella could grow and spread. 4. Decide where to apply and how to monitor control measures. 5. Establish interventions when control limits are not met. 6. Ensure the program runs as designed and is effective . During an interview on 05/08/25 at 2:45 PM the Director of Nursing (DON) presented water testing results for the facility's activities room, and empty resident room [ROOM NUMBER]. When asked if the facility had a process for evaluating all areas identified by the facility as potential sites for Legionella growth, the DON stated she only had testing results date 01/24/25 for the activities room and room [ROOM NUMBER]. When asked for a water management program that governed the facility's Legionella prevention program, the DON stated she would look for it. When asked who was responsible for the facility's water management and legionella program, the DON stated she was responsible for the program. During an interview on 05/08/25 at 4:29 PM, the DON admitted the facility did not have a Legionella prevention program. Per the facility's policy, the DON admitted she had not: 1. Established a WMP (water management program) team; 2. Described the building's water systems; 3. Identified areas where Legionella could grow and spread in the facility; 4. Decided where to apply and how to monitor control measures. 5. Established interventions when control limits are not met. 6. Ensured the program runs as designed and is effective.