**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Kitchen On 1/21/25, at 9:32 a.m., during a brief initial tour with the interim culinary director (CD)-A and the certified dietary manager (CDM), an observation was made of completion of the dishwashing process. At that time, the temperatures for the morning cycle temperature check had not been logged. Dietary aide (DA)-B stated the wash temp was 150 degrees Fahrenheit, and the rinse temp was one hundred and eighty five-ish. DA-B stated the temperatures were to be 160 for wash, and 180 for the rinse cycle. Although able to state the desired temperatures for the wash and rinse cycle, DA-B stated she was unaware the temperatures were to be up to the desired temperatures before starting the dishwashing process and was unaware there were further interventions indicated if the machines did not reach the desired temperatures. CDM, who was present during the observation and interview, stated it appeared that staff were unaware of the need to run two or more racks through to bring the temperatures up to the desired temperatures prior to starting the dishwashing cycle, and instructed DA-B on this process. CDM stated if the dishwashing machine was not up to the required temperature when checked, the dishwasher would have to be run until the temp was up to the desired temp. If the temperature still did not get to the desired temp, the facility would have to reach out to the company and request a service call. CD stated if this could not be corrected, the facility would use the three section sink for cleaning of pots and pans, and implement use of Styrofoam plates. On 1/22/25, at 1:52 p.m. during a follow up observation, DA-C was observed as they completed the dishwashing process. A review of the recorded temperatures indicated the temp check for the wash temperature was 175, while the rinse cycle was at 178 degrees Fahrenheit. DA-C stated they were unaware of the need to run the racks through until the temperature met the desired temperatures of 160 for the wash cycle and 180 for the rinse cycle. CD-A was present and provided instruction to DA-C. A review of the dishwasher temps was completed for the period of 12/12/24 to 1/21/25. The facility documentation lacked logged results for the period of 1/1/25 through 1/7/25 (42 opportunities for documentation were missed during this time period). The wash temperature was below the desired range on 36 occasions during the period of 12/12/24 to 1/21/25. The facility also lacked documentation for wash temperature checks on 27 opportunities during this period. This total, including the missing documentation for 1/1/25-1/7/25, would be 48 incidents when wash temperatures were not recorded. The rinse temperature was below the desired range of 180 degrees Fahrenheit on 10 occasions during the period of 12/12/24 to 1/14/25. The facility also lacked documentation for rinse temperature checks on 28 opportunities during this period. This total, including the missing documentation for 1/1/25-1/7/25, was 49 occasions where rinse temperatures were not recorded. On 1/23/25, at 8:50 a.m. the service representative (SR) for the dishwasher was present for a service call. At this time, the wash and rinse temps were checked three times. SR stated the required temp for washing of dishes was 160 degrees. SR went on to state The final rinse temperature can be no lower than one hundred and eighty degrees. SR stated it was recommended to run the dishwashing racks through a couple of times to get the temperature up to the appropriate temperature. SR stated the water has to be that hot (180 degree rinse temperature) to kill the bacteria, and stated If not sanitized properly, technically you're not washing. SR stated the potential implication of not having the correct temperatures at 180 degrees Fahrenheit was: People can get sick. That's the whole point of sanitizing. On 1/23/25, at 9:04 a.m. a review of the current logs was completed with CDM. CDM stated it appeared staff were not aware to run the dishwasher racks through the machine two or more times to get up to temperature. CDM stated the purpose of monitoring temperatures was to ensure the dishwasher was operating correctly, to ensure that the dishes were cleaned and sanitized. CDM went on to state: If the dishes were not sanitized, and if the dishes were not clean, there was a risk, potential risk, for illness. CDM stated currently in the facility, she was aware of the presence of COVID and influenza, however, was unaware of any residents with Norovirus. CDM stated there were residents with Norovirus prior to January of 2025. CDM stated she was unaware of the length of time Norovirus could remain on dishes if not cleaned properly. On 1/23/25, at 9:54 a.m., CD stated he was not aware of any residents who required special precautions at this time. CD stated dietary is notified by the infection preventionist of any new illnesses, and if they need to use paper products to eliminate cross contamination. On 1/23/25, at 2:43 p.m., an email, dated 12/27/24 at 8:39 a.m., sent by the CD, was provided by the IP and administrator. The email stated In the event of instances like Norovirus that we have/had in the TCU, we would be using disposable items for meals wherever applicable. The email went on to state This reduces the amount of contact with items amongst the teams. As this surveyor had been told earlier by the CDM and CD there were no current cases which required disposable items, this was clarified with IP and administrator. The IP stated there was one case of Norovirus in the facility. IP stated use of disposable products was implemented when Norovirus was suspected. IP went on to state there were four total rooms where disposable dishes were being used. IP stated this was implemented upon suspicion of Norovirus. IP went on to state she was in contact with the CDM and CD and they were aware of people using paper products. Although paper products were implemented for those four residents as outlined by IP, the paper products were delivered on plastic trays, which were washed through the communal dishwasher. On 1/24/25, at 10:13 a.m., surveyor stopped at the receptionist desk for directions. At that time, surveyor observed a credit card scanner on the counter top, and asked it's function. The receptionist stated it was for employees to pay for their meals when they eat the facility food. Policies The facility Standing Orders for Skilled Nursing Facilities, revised 2023, identified facility to complete COVID-19 PCR, NAAT, Influenza/RSV/COVID-19 PCR, and/or antigen testing as indicated for outbreak and/or routine testing per facility policy. If a resident is symptomatic: completed rapid COVID-19/Flu A&B, COVID-19 PCR, NAAT, Influenza/RSV/COVID-19 PCR, and/or antigen testing. The facility Principles for Screening Staff Illness, undated, identified staff having active symptoms (fever, significant coughing, uncontrolled sneezing, runny nose, diarrhea, and vomiting) should not work. Types of Illness: Respiratory illnesses - including cough, congestion, fever, chills, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, and runny nose. (Diarrhea, nausea or vomiting can also present with COVID-19 infections.) Staff should not work until return-to-work screening criteria have been met. If staff has respiratory symptoms and does not comply with testing, they may return to work on day 11 after onset of symptoms. GI Illnesses -vomiting and/or diarrhea symptoms should not work with active symptoms. Sore throat - sore throat that does not resolve in 48 hours and COVID and influenza have been reasonably ruled out, strep testing is recommended. Return to work protocol: - Staff with improving or mild respiratory symptoms and no fever for 24-hours without fever reducing medications can return to work after two negative rapid antigen tests 48-hours apart or return to work or stay at work with one negative NAAT. Since influenza symptoms are similar to COVID, if influenza is suspected either from known exposure or a negative COVID test but significant symptoms exist, conduct rapid influenza/COVID-19 test. If negative, employee may return to work when symptoms improve. - Influenza Positive: Seven (7) after onset of infection, no fever for 24 hours without fever reducing medications, and improving symptoms. - GI Illness: Forty-eight (48) hours after no active symptoms (vomiting and diarrhea) * and no fever for 24 hours without fever modification medication. Norovirus outbreak, Nursing is 72-hours. In general, dietary staff 72 hours after GI symptoms end before returning to work. - Sore throat: Improvement of symptoms. If sore throat does not improve within 48-hours suggest negative strep test, if positive strep test 24-hours on antibiotics. (MDH is 24-hours and CDC is 12-hours). - In general, infectious bacterial infections being treated with antibiotics- staff can return after 24 hours of starting antibiotics. Some serious infections may require longer antibiotic treatment before being deemed noncontagious. - GACC adheres to CDC and MDH guidelines for return-to-work protocol. The facility Standard and Transmission-Based Precautions policy, date 1/25, identified standard and transmission precautions will be used for residents in standard care and who are documented or suspected to have an infection or communicable diseases that may be transmitted to others. The organization is compliant with standard transmission-based precautions as recommended by the Centers for Disease Control and Prevention. - Purpose is to decrease the risk of cross-contamination to other residents, staff, volunteers and visitors. - Standard Precautions are practices to reduce healthcare associated infections are used with all patients, regardless of diagnosis or isolation status, and apply to interacting with blood, body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood, non-intact skin and mucous membranes. The required elements include: Adequate hand hygiene at all appropriate times. - Disinfecting surfaces and equipment between patient uses. - Appropriate use of Personal Protective Equipment (PPE) (e.g., gowns, gloves, mask, eye protection) for reasonably anticipated contact with body substances or contaminated equipment. Standard Precautions take into consideration the task being performed, e.g. gloves and mask with face shield for emptying drainage bags. - Safe injection practices. - Respiratory Hygiene/Cough Etiquette. Transmission-based precautions are used for residents who are documented to have or suspected to have an infection or communicable disease where transmission cannot be controlled using standard precautions alone. Transmission-based precautions are used in addition to standard precautions. The type and duration of precautions is determined by referencing the CDC's Type and Duration of Precautions Recommended for Selected Infections and Conditions, or other CDC recommendations for diseases and conditions not listed in the recommendations section. The six types of transmission-based isolation include: - Contact Precautions: gloves and gowns when entering resident room. Use of mask, eye protection/face shield as needed. - Enteric Contact Precautions: gloves and gown when entering resident room. Wash hands with soap and water and use bleach (or disinfectant specific for enteric virus) for cleaning surfaces. - Droplet Precautions: gloves and gowns when entering resident room. Use of mask, eye protection/face shield as needed. - Special Contact and Droplet Precautions: gloves. gowns, fit-tested, NISOSH approved N95 or higher-level respirator and eye protection. - Enhanced Barrier - gown and gloves during high-contact resident cares due to indwelling devices, wounds, and/or MDROs status - Airborne Precautions gloves, gowns, fit-tested, NI [NAME] approved N95 or higher-level respirator (or PAPR) and eye protection - these residents require immediate transport to a level of care that can appropriately care for airborne infectious disease (ex. TB). Isolation: - Post a notice on the door of the resident's door of isolation. - Post appropriate precautions sign. - Provide isolation cart with necessary PPE outside resident room. Visitors should be discouraged from visiting when the visitor has an infectious condition. All staff that has contact with the resident(s) will be in serviced on appropriate Precautions. Gloves and Handwashing - In addition to wearing gloves as outlined under Universal/Standard Precautions, wear gloves (clean, nonsterile) when entering the room. - During the course of caring for a resident, change gloves after having contact with infectious material that may contain high concentrations of microorganisms (i.e. fecal material and wound drainage). - Gloves should be used for handling of all laundry of infected resident. - Remove gloves before leaving the room and cleanse hands immediately in accordance with the hand hygiene policy and procedure. - After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident's room. Gown - In addition to wearing a gown as outlined in Universal/Standard Precautions, wear a gown (clean, nonsterile) when entering the room if it is anticipated that clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent, has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. - Remove the gown before leaving the residents' room. - After gown removal, ensure that clothing does not contact potentially contaminated surfaces. The Director of Nursing, Infection Preventionist, and Administer are responsible for monitoring cross-contamination, need for prophylactic treatment (e.g. Tamiflu). and reporting requirements for MDH. The facility Infection Control policy, dated 1/25, identified signs and symptoms of infections will be promptly recognized by staff, documented, and communicated to the medical provider teams. Employees will follow accepted standards to decrease risk of organism transmission/cross-contamination including use of personal protection equipment (PPE), universal/standard precautions and isolation precautions. All nursing staff will be made aware of antibiotic stewardship to avoid Multidrug Resistant Organisms (MDROs). Treatment/reporting procedures will be consistent with regulatory requirements per Federal and State guidelines. Purpose is to ensure all staff are aware of/familiar with infection control protocol at GACC. Recognize Infection: - Staff will use available resources will identify infections and initiate steps to treat. - Monitor vital signs, assess physical and mental changes in condition. Use disease specific assessment skills, i.e., respiratory assessment must include TPR, B/P, oxygen saturation, use of accessory muscles of respiration, lung sounds, resident's color, presence/absence of sputum - sputum color. Document findings Communicate assessment of findings to physician for determination of treatment. Surveillance: - Provide procedures with ongoing review for accepted standards to reduce transmission of infections. - Monitor antibiotic use to meet guidelines established. - Monthly review of patterns and trends by unit. - Residents will not be admitted with active infection, i.e. influenza, Tuberculosis, Ebola, SARS. No availability of negative pressure isolation room. - Resident placement to minimize exposure - considerations: private room, cohabitation, double room with limited ability to cross contaminate (c diff, MRSA). - Posting of signs in facility to remind staff and visitors of infection standards. Initiate as needed restrictions to facility or nursing wings. Sample sign STOP! Help Protect Our Residents - Environmental cleaning and disinfection of equipment/supplies by departments procedures. - Proper use and provision of personal protection equipment. Isolation Precautions - Designated cart with supplies is located in the employee education room. - Hazardous waste removal to designated location-300 wing north hall and 500 wing. TRAINING OF STAFF I EMPLOYEE HEALTH - Staff training provided at orientation, annually, and ad hoc. - Annual offering of influenza and COVID-19 vaccines to staff. - Annual questionnaire for Tuberculosis screening. - Refer to /Cross reference with facility's Exposure Control Plan. REPORTING - Staff will complete infection control report when infection identified. - ICC nurse will submit monthly compilation report to DON, along with any identified trends. - Infection statistics and trends will be documented on QA reports with presentation at scheduled meetings. - Employee health infections/trends are tracked. Any transmission to residents will be communicated - Infection control reports per clinical software, review for unnecessary use of antibiotics. - Determine as needed reportability to Minnesota Department of Health The facility Surveillance for Infections policy, dated 1/25, identified the infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. The criteria for such infections are based on the current standard definitions of infections. Infections that will be included in routine surveillance include those with: - evidence of transmissibility in a healthcare environment. - available processes and procedures that prevent or reduce the spread of infection. - clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTl's, C. difficile); and - pathogens associated with serious outbreaks. (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza, COVID-19). Infections that may be considered in surveillance include those with limited transmissibility in a healthcare environment; and/or limited prevention strategies. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible. If a communicable disease outbreak is suspected, this information will be communicated to Nurse Manager and infection preventionist immediately. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. Staff nurse will notify the attending physician and the infection preventionist of suspected infections. - The infection preventionist and the attending physician will determine if laboratory tests are indicated, and whether special precautions are warranted. - The infection preventionist will determine if the infection is reportable. - The attending physician and interdisciplinary team will determine the treatment plan for the resident. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the infection preventionist will collect data to help determine the effectiveness of such measures. When transmission of healthcare-associated infections continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or a specialist in infection control and epidemiology will be consulted for further recommendations. A facility policy, Dishwasher Temperature, undated, indicated the purpose of monitoring the dishwasher temperature was to ensure that proper infection control, cleaning and sanitizing of all dishware is achieved while using the automatic dish machine. The policy statement identified: The automatic dish machine will reach the appropriate temperature prior to washing and sanitizing to meet the guidelines. The procedure outlined prior to washing the dishes, the dish machine will be turned on and run through the cycles to identify wash and rinse temperatures. The procedure identified the wash cycle will reach and minimum temperature of 160 degrees and rinse cycle will reach and maintain a minimum temperature of 180 degrees. The procedure identified the dish machine will be monitored at each meal period to ensure proper wash and rinse temperatures are reached. If the temperature was below the specified temperatures for the wash and rinse cycle, the Engineering department will be notified immediately. The procedure went on to state dishes will not be washed until the dish machine reaches the appropriate temperature. The procedure further goes on to identify If needed, disposable dishes will be used until the proper repairs can be made, and the three-compartment sink method will be used for pots and pans. The policy lacked direction to staff to run multiple racks prior to starting the process to bring the cycles up to the desired rinse cycles prior to starting the dishwashing process. Additionally, the policy lacked instruction to the staff to record the temperatures obtained on the dishwasher temperature logs upon obtaining the temperatures. The manufacturer manual from American Dish Service for Model ADC-44 High Temp Conveyor Dishmachines [sic], last revised 4/28/21, was received from the facility. The manual indicated the requirement at the dishmachine is 180 F (degrees Fahrenheit). The manual identified for high temp sanitizing, the measurement is taken at the manifold for a minimum of 180 F, not in or at the sprays. The manual indicated the temperature for hot water sanitizing in the wash cycle should be 160 F and 180 F for the rinse cycle for the hot water sanitizing. The IJ that began on 1/21/25 was removed on 1/24/25 when it was verified through observation, interview and docuement review, the facility implemented the following: 1. 108 out of 108 residents were audited for respiratory and GI symptoms. Any residents that were identified as suspected illness were placed on the appropriate precautions based on symptoms per CBC/MDH guidelines. 2. Revised and educated staff on the infection control policy to include updated signs and symptoms, HER order sets, timing of residents being placed on isolation precautions, staff attesting to absence of respiratory and GI symptoms, partnership with culinary and IP. Infection control policy included implementation of isolation by clinical staff upon identification of onset of respiratory and/or GI symptoms. 3. Revised the dish machine temperature log and dish machine temperature log and operations expectations policy. Per the current policy and procedure identified on the dish machine log, indicated instructions are outlines if temperatures are not reached on who to contact until the machine can properly function. Disposable dishes will be used until repairs are made. Culinary staff are trained on expectations and policy. 4. Implementation of episodic monitoring of residents during outbreak periods will be initiated every shift utilizing an outbreak monitoring order set. Order set will be completed by nursing in the EMAR. Order set for outbreak monitoring will include supplementary documentation for respiratory or GI illness dependent on the outbreak. 5. New notification process for dietary of GI illness. A new form was developed and trained upon to ensure communication between clinical and dietary staff related to any GI illness updates to ensure appropriate meal delivery takes place. Dietary will receive the new form from clinical and process the request. New meal delivery process will be initiated for the resident identified by clinical. Tray cards will be updated with the new information. This will not be discontinued until IP or designee communicates removal with dietary department. IP will upload a note in PCC. 6. Updated process for monitoring employee illness and return to work status. Per the new employee illness policy and procedure, staff are unable to return to work until they are cleared by Infection Preventionist, HR, or designee based on CDC guidelines. 7. Based on updated communication posters that are posted on resident rooms by clinicians as needed, and following updated education for all staff, staff are being instructed to read and follow the guidelines displayed on the posters. Administrator or designee will continue to notify all staff on outbreaks within the facility. 8. Continue to track on MDH surveillance log while ensuring no gaps and continued auditing of surveillance log by Infection Preventionist or designee. Auditing will be conducted by DON or designee. 9. All staff within the community, regardless of roles and departments, will be educated on precautions, appropriate PPE, and regular hand hygiene. Routine audits will be conducted to ensure compliance and addressed at quarterly QAPI. 10. Staff education on infection control practices, policies and procedures that related to Norovirus and Influenza A outbreaks, improper dishwasher sanitation, and appropriate PPE usage had been implemented. Based on observation, interview and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Influenza A and norovirus. In addition, the facility failed to ensure infection control measures were implemented to reduce the spread of Norovirus when the dishwasher temperature did not rise high enough to sanitize the dishes during the norovirus outbreak. As a result, the facility developed an influenza outbreak which included three residents (R26, R29, and R71) who tested positive for Influenza A, and two residents who were suspected to have Influenza A (R54, and R216) as well as 10 residents (R87, R207, R346, R54, R84, R85, R23, R205, R216 and R209) who showed signs and symptoms and/or were confirmed to have norovirus. The facility failed to ensure 12 of 12 employees, (registered nurse (RN)-E, cook (C)-A, dietary aide (DA)-D, laundry aide (LA)-B, nursing assistant (NA)-D, housekeeping aide (HA)-C, DA-E, NA-E, RN-F, NA-F, NA-G, and NA-H) who displayed signs and symptoms of potential Norovirus were restricted from and returned to work per the Centers for Disease Control (CDC) criteria. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility to vulnerable residents and the staff of the facility resulting in an immediate jeopardy (IJ) which placed all 108 residents at a high likelihood to for serious illness and/or death by contracting a communicable disease, including but not limited to Norovirus and/or Influenza. The IJ began on 1/21/25 when R26 was observed to have influenza-like symptoms, and the facility failed to implement appropriate transmission-based precautions to prevent spread of infection and failed to implement infection control surveillance to identify trends or patterns of potential infectious outbreaks. In addition, after the facility placed residents in isolation, staff were observed to not use the appropriate PPE and/or perform appropriate hand hygiene practices. Norovirus outbreak started in December and continued to spread in facility at the time of the recertification survey. The IJ was identified on 1/23/25, and the administrator, director of nursing (DON), director of quality improvement (DQI), infection preventionist (IP) and executive business director were notified of the IJ on 1/23/25 at 5:45 p.m. The IJ was removed on 1/24/25, at 1:45 p.m., when the facility implemented actions to reduce/prevent the spread of illness, including Norovirus and Influenza A. However, noncompliance remained at the lower scope and severity, F, widespread, which indicated no actual harm with potential for more than minimal harm that was not IJ. Findings include: The U.S. Centers for Disease Control and Prevention (CDC) identified Influenza is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs. The Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities, dated 9/17/24, identified when there is influenza activity in the local community, active daily surveillance for influenza illness should be conducted among all new and current residents, healthcare personnel, and visitors of long-term care facilities, and should be continued until the end of influenza season. Healthcare personnel, and visitors who are identified with any illness symptoms should be excluded from the facility until their illness has resolved. Older adults and other long-term care residents, including those who are medically fragile and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms of influenza virus infection, and may not have fever. Ill residents should be placed on droplet precautions with room restriction and be excluded from participating in group activities. Influenza testing should occur when any resident has signs and symptoms of acute respiratory illness or influenza-like illness. Implement standard and droplet precautions for all residents with suspected or confirmed influenza. Standard precautions are intended to be applied to the care of all patients in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of Standard precautions constitute the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel. Standard precautions consist of performing hand hygiene, using personal protective equipment (PPE) whenever there is an expectation of possible exposure to an infection material, follow respiratory hygiene/cough etiquette principles and properly handle, clean and disinfect patient care equipment and instruments/devices. Clean and disinfect the environment appropriately. The U.S. Centers for Disease Control and Prevention (CDC) identified Norovirus as a very contagious virus that causes vomiting and diarrhea, that sometimes is called the stomach flu or the stomach bug; however, norovirus illness is not related to the flu. The flu is caused by the influenza virus. Norovirus causes acute gastroenteritis (inflammation of the stomach or intestines). Most people with norovirus illness get better within one to three days; but they can still spread the virus for a few days after. A person usually develops symptoms 12 to 48 hours after being exposed to norovirus. Most common symptoms: diarrhea, vomiting, nausea, stomach pain with other symptoms that may include fever, headache. The virus can be introduced into healthcare facilities by infected patients, staff, visitors, or contaminated foods. Compared with healthy people, norovirus illnesses can be more severe and occasionally even deadly in patients in hospitals or long-term care facilities. Anyone can get infected and sick with norovirus and people of all ages get infected during norovirus outbreaks. Older adults and people with weakened immune s[TRUNCATED]