**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have an Infection Control program and system in place to track or trend illnesses, failed to have a process to identify contagious residents, and failed to implement transmission based precautions for residents exhibiting infectious illness. This applies to all residents residing in the facility. These failures resulted in 19 residents (R1,R3,R5,R6,R8,R9,R11,R13,R14,R16,R18,R21,R23,R25,R29,R30, R35,R39,R42) experiencing gastrointestinal and respiratory illness. The Immediate Jeopardy began on 12/26/22 when R13 and R14 began having symptoms of being tired and rundown, and sore throat, congestion, and cough with green sputum. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/5/23 at 1:32PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/6/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: A review of electronic medical records showed: On 12/26/22, R13 reported being very tired and rundown and R14 experienced increased sore throat, congestion, and cough with green sputum. On 12/28/22, R23 experienced nausea and vomiting. On 12/31/22, R1, R3, R25, and R42 experienced nausea and vomiting while R18 and R35 experienced cough, sore throat, and congestion. On 1/1/23, R6 experienced coughing and wheezing. R21 experienced vomiting and R30 experienced a sore throat and cough. On 1/2/23, R5 experienced loose stools and R39 experienced sore throat and congested cough. R13 began experiencing a sore throat, green sputum, and congestion. On 1/3/23, R11 and R16 experienced several episodes of diarrhea. On 1/4/23, R29 experienced fatigue, cough, and congestion. On 1/4/23 at 1:19PM, V2 (Director of Nursing) stated, There were several residents over the weekend with a gastrointestinal illness but I would have to look at every single resident's progress notes to figure out who they were. I didn't track them because it was the weekend. At 1:30PM, V2 then provided the facility's document titled, Respiratory Symptom Pursuit for 9 residents in the building. V2 stated these were all of the residents who have been ill and no new residents have displayed any symptoms. At this time, surveyors had identified 17 residents who had become ill with respiratory or gastrointestinal symptoms. On 1/4/23 at 3:05PM, V1 (Administrator) stated, We don't exactly have an infection control program. I know (V2) looks at infections but we don't do anything with the documentation. We just don't have the resources to dedicate someone to just look at infections. I'm not sure how often our policies are updated and reviewed but I know they are current with the standard of practice. I heard about the illnesses over the weekend but to my knowledge everyone is doing fine and better. We don't have a contact at the local health department and we did not reach out to them about this outbreak. I guess I didn't realize we had to or should have. As of 1/4/23 at 3:15PM, none of the above residents had been placed on transmission-based precautions for their symptoms, no contact had been made between the facility and the local health department regarding an illness outbreak, and no infection tracking had been initiated for an outbreak of a potentially contagious illness. On 1/5/23, R9 experienced congestion, productive cough with yellow and green sputum. R8 began experiencing a cough with yellow sputum. On 1/5/23, R9 was sent to a local hospital due to her respiratory symptoms. R9's medical records showed, Patient here with complaint of shortness of breath, cough, generalized weakness and fatigue, increasing lethargy over the past 2 days. Patient was noted to be hypoxic to the high 80s on room air at facility, sent to the emergency room for further evaluation. She is on 3 liters nasal cannula. She does sound wheezy on lung exam, crackles to bilateral bases, my concern is for infectious process including pneumonia R9's diagnostic radiology report dated 1/5/23 showed, Impression: 1. Small bilateral pleural effusions with nonspecific bibasilar opacity, which can be seen with atelectasis or consolidation. Infection is not excluded if there is clinical suspicion. On 1/5/23 at 10:22AM. V2 stated, I have a book of other infections other than COVID. I print a spreadsheet and put it in the book but we don't do anything with it really. We discuss COVID in our Quality Assurance Performance Improvement (QAPI) meetings but don't necessarily discuss any other infections. We don't have an actual infection control program but we are working on it. Over this past weekend I was called for two residents that were sick with diarrhea and vomiting and there were a few that had respiratory symptoms. I told the staff just to try and keep those residents in their rooms and bring meal trays to them. I didn't see it as an outbreak necessarily because we didn't have a large group of residents that were ill. None of the residents that have been experiencing symptoms have been placed on transmission based precautions. We had one resident (R13) that has been tested for influenza but it was negative. No other residents were tested for influenza. I'm guessing we would report all illnesses to the health department. We did not call the health department for this illness. I didn't really think about it. It was the weekend and nobody was there so I don't even know who I would call. We have not identified any new residents other than the 9 resident symptom pursuit sheets I gave you. There are no new residents other than the initial 9 I gave you. It's like nothing ever happened. The only symptoms the residents had were vomiting and diarrhea so I don't even know what we do for them besides keep them comfortable, hydrated, and give an antiemetic if needed. The symptom tracker sheet is the main way we keep track of these illnesses. Residents are assessed every shift for 72 hours or until symptom free. If a resident is not getting better after 72 hours or the resident has increased symptoms then we would reach out to the physician again for further orders. I did have the nurses start a symptom pursuit form for the 9 residents to keep track of their illness. It is more of a visual aide and reminder for them to check on the residents. At this time, the facility had only identified symptoms for R1,R11,R13,R16,R18,R21,R25,R30, and R35. On 1/5/23 at 11:05AM, V21 (Director of Clinical Services-Health Department) stated, If there is an outbreak within a facility I am usually in contact with the Director of Nursing or the Administrator. Each facility should have a list of illnesses or symptoms that should be reported to the health department and when they should be reported. I have not received any communication from the facility regarding any recent outbreak of illnesses. If the facility is having any outbreak of a potentially infectious disease I would say 2 or more residents is an outbreak that should be reported to us. The facility has access to my phone number and I am available 24/7 so I can be reached any time. If the facility would have contacted me I would have asked for further information regarding what is going on and ask as many questions as I can. I would go through the Illinois Department of Public Health (IDPH) for specific pathogen guidance if we know the organism. It's on the IDPH web portal for them also but I would go over that and share the guidance with them. I would link them up with people at the state if it was more than I could handle. If the cases seem like they are all linked, I would wonder if its food borne or viral illness. I would have suggested they contact the physician and get an order to do stool testing done to see if we could find exactly what we were dealing with. If we suspected it was food borne illness we would go one route and viral another route. If it was something we thought could be food borne we would get our environmental health on board and get a kitchen inspection going, contact IDPH and go from there to determine what the pathogen is. There are so many avenues to this and so much tracking and documentation I would need to see to start making recommendations. They should have jumped into action within the first few cases to prevent an outbreak of this illness. Now they are behind on testing residents stool and testing for possible influenza. If it was a foodborne illness then it may be too late to try to get that information because they did not report it to me immediately. The purpose of the facility reaching out to us is so we can provide them guidance for infection control, find out what is going on, and stop it as soon as possible. They should contact us early when there is a small amount of cases and we could help them determine the cause and prevent further exposure and spread. On 1/6/23 at 11:33AM, V2 stated, In the residents electronic medical record program there is an infection control section that you can monitor infections. It's called a symptom pursuit and that's similar to what we use on paper and document in the system. The symptom pursuits go on the communication board on the dash board within the electronic charting program. I go over that every day. I guess I didn't see the new symptom pursuits for the additional residents you identified. I use the [NAME] Criteria for Infection Surveillance. The facility's undated policy titled, Communicable Disease Reporting showed, Objective: To establish policy in compliance with Illinois law for mandatory reporting of communicable diseases; as indicated per the IDPH rule and guidelines for reporting of communicable diseases .4. Suspected clusters of diseases, which may not be reportable at the time, may also be recorded on a log, and shall be reviewed and monitored per infection control officer, or designee .11. Per IDPH: Certain infectious disease with public health significance shall be reportable by phone, as soon as possible within 3 hours, to the appropriate local health department .b. Any unusual case or cluster of cases that may indicate a public health hazard. On 1/5/23, V2 provided surveyors with the Revised McGeer Criteria for Infection Surveillance Checklist that she uses for guidance on monitoring and reporting purposes. The undated criteria showed, Gastroenteritis: In the presence of an outbreak, stool specimens should be sent to confirm the presence of norovirus or other pathogens. The facility's undated policy titled, Infection Control and Standard/Isolation Precautions showed, Objectives: To protect residents, visitors, students, and staff from communicable diseases and healthcare-associated infections .5. The nurse or physician shall institute and maintain isolation techniques as required by .suspicion of disease or as recommended by infection control officer. The Immediate Jeopardy that began on 12/26/22 was removed on 1/6/2023 when the facility took the following actions to remove the Immediacy. Administrative staff consisting of DON, and Administrator, completed a review of the current resident roster of 45 residents to determine any unidentified cases of illness presented on 1/5/23. No new residents were identified with GI or respiratory symptoms as of this date. The 19 residents identified who presented with GI/respiratory symptoms beginning 12/26/22 thru 1/5/23 were assessed for ongoing symptoms effective 1/5/23. Of those 19 residents, 1 resident identified will have a stool specimen collected as soon as possible. Primary care provider was notified and order obtained for GI panel. 8 of the 19 residents identified currently are exhibiting respiratory symptoms. Of these 8 residents, 1 resident was hospitalized [DATE] and tested for influenza and COVID, results were negative for both influenza and COVID. 1 resident is currently being treated for aspiration pneumonia and PCP declines need for respiratory panel. The remaining 6 residents have had nasal swabs obtained for an expanded respiratory panel on 1/5/23 as orders were obtained from primary care providers. R25 was moved to a private room for isolation effective 1/5/23. R29 was moved to a private room for isolation effective 1/5/23. R11 was isolated in his room as his roommate was moved to another room. He will remain in another room for the duration of the isolation effective 1/5/23. The Medical Director, was notified of GI/respiratory symptoms outbreak on 1/5/23. The Local Health Department Communicable Disease Nurse was notified by of the GI/respiratory symptom outbreak in the residents. Discussion took place regarding resident surveillance of symptoms, isolation, testing of residents, and appropriate cleaning measures. The DON has identified a surveillance tracking tool within the Point Click Care documentation system. The DON is completing the surveilling tracking within Point Click Care. This tool has been completed effective 1/5/23 for the current 8 residents that are exhibiting GI/respiratory symptoms. The surveillance tracking tool will be utilized when any resident develops symptoms which could be considered to be communicable or transmissible to others. The nursing staff will be educated by the DON RN, by 1/10/23. The Infection Control Coordinator will audit to ensure nursing staff is using the surveillance tracking log as part of her daily assignment. This data will be utilized to help identify when 2 or more residents have similar symptoms within 72 hours and the Local Health Department needs to be notified. Maintenance staff completed a deep clean of the facility to include high touch surfaces with use of an EPA registered appropriate cleaning product. High touch areas within the facility will be cleaned three times a day beginning 1/6/23 until symptoms resolve. Quality Assurance will be completed by the administrator with staff completing a daily log to ensure this is done three times per day when two or more residents have similar symptoms within 72 hours. This log will be reviewed daily. Administrative staff and the Infection Control Coordinator were trained on facility response to illness outbreak by the Local Hospital Infection Control Nurse and the Local Health Department Public Health Communicable Disease Nurse. This training included a review of Appendix A Type and Duration of Precautions found on the CDC website and the need to contact the local county health department at any time when there are 2 or more residents identified with similar symptoms within 72 hours of onset. Staff training took place on 1/5/23 at 4:30PM with all staff currently on shift. Training was completed by the local hospital Assistant DON. This training included the importance of hand hygiene, increased frequency of cleaning/disinfecting including high touch areas, reporting of resident symptoms to the shift nurse, and isolation protocols. The Administrator, returned to educate 3rd shift and arrived at 7AM to educate first shift. Please see sign-in sheet. As of 1/6/23 at 7:00AM, 26 employees received this education and the remainder of staff will be educated at their next scheduled shift up and until mandatory meetings that are scheduled for 1/10/23 for all staff. 3 different meeting times are scheduled for 1/10/23 which will include this education and it will be an opportunity for some staff to hear it twice. The Hospital CEO, will touch base with the administrator five days per week for the next three months to ensure that these plan of correction measures are being carried out. The Infection Preventionist, will be responsible for the new infection control program. An infection control program/committee will consist of the administrator, DON, a designated floor nurse, a designated CNA and a designated housekeeper and/or designated maintenance member. This committee will meet on a monthly basis. The Infection Preventionist will provide an infection control report at the quarterly quality assurance meetings. The Hospital CEO will attend the quarterly quality assurance meetings. On 1/6/23 at 12:00PM, a review of the facility's in-service record showed all staff working the remainder of the day on 1/5/23 and staff working on 1/6/23 were in-serviced on infection control procedures consisting of identifying and monitoring residents for symptoms, notification to nurse for residents identified as having new symptoms, isolation of potentially contagious residents, hand hygiene, and disinfection of high touch surfaces. As of this time, 44% of the entire staff had received the in-service training with the remainder of the staff receiving the education prior to the start of their next shift and/or on scheduled in-services on 1/10/23.