**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ONGOING INFECTION CONTROL SURVEILLANCE: The faciltiy provided an Infection Surveillance Report for each month that included resident name, case details, symptoms, lab results, treatment details and outcome. The facility Infection Surveillance Report dated January 2025, was reviewed and failed to include R13's influenza A exposure and symptoms. R13 R13's annual Minimum Data Set (MDS) dated [DATE], identified R13 had a severe cognitive impairment and diagnoses that included congestive heart failure (CHF), hypertension and type 2 diabetes. R13's nursing progress note dated 1/6/25, identified R13 was exposed to influenza A from roommate. R13 was also experiencing respiratory symptoms so R13 was swabbed for a respiratory panel which has been sent to the lab. Results pending. The facility Infection Surveillance Report dated February 2025, failed to include R34's respiratory signs and influenza A positive status, R34 R34's significant change MDS dated [DATE], identified R34 had a severe cognitive impairment and diagnoses that included atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension and dementia. R34's nursing progress notes identified: - 2/12/25 at 4:29 p.m., R34 from a nap this afternoon with a hoarse voice and dry cough. No fever noted or any other symptoms at this time. - 2/13/25 at 2:13 p.m., R24 continued to have a hoarse voice today and dry cough. She also had a low grade temp this morning. Resp Panel swab completed at 4:00 p.m - 2/13/25 at 2:14 p.m., R18 was sleepy today. Was running a low grade temp this morning. R34 received scheduled Tylenol. She was complaining of pain in her right shoulder and right hip. Pain meds were effective. R34 has not eaten well today but has been drinking fluids when given to her. R34 was propelling herself around in her wheelchair more. PT works with R34 daily. - 2/13/25 at 8:33 p.m., R34 wanted to go to bed soon after supper, she appeared tired, not as talkative as usual when asked she denied any pain, no coughing noted this shift, awaiting results of resp panel. Currently R34 asleep in bed respirations easy and regular at 18. R34 was able to get place to place by wheeling wheelchair and appeared to tolerate well. - 2/14/25 at 6:51 a.m., R34 tested positive for influenza A. Isolation precautions set up on R34's door. R34 was experiencing a low grade temp, cough, and hoarse voice. A skilled nurse is monitoring signs and symptoms. Plan of care ongoing. During an interview on 2/26/25 at 3:41 p.m., RN-A stated every day RN-A was scheduled to work, RN-A read through either the 24 hour or 72 hour report. For example, if RN-A did not work the weekend, RN-A would review the 72 hour report on Monday mornings. When RN-A was not working, there was no designated staff member to complete resident illness surveillance. Any resident with any sign or symptoms of infection should have been documented on the surveillance log to prevent the spread of illness. During an interview on 2/27/25 at 4:18 p.m., the DON stated all signs/symptoms of illness were expected to be documented and entered on the surveillance log to prevent the potential spread of illness. The facility policy Infection Surveillance revised 2/25/25, identified the facility would conduct ongoing surveillance for Healthcare-Associated Infections (Thais) and epidemiologically significant infections that have substantial impact on potential resident outcome. Based on observation, interview and document review, the facility failed to implement transmission-based precautions (TBP) for respiratory symptoms until confirmatory respiratory test results were obtained for 6 of 38 residents (R34, R31, R11,R22, R36, R32), failed to initiate droplet precautions for 1 of 6 residents (R31) known to test positive for influenza A, failed to implement strategies to mitigate the risk of an influenza outbreak, including initiating active surveillance of residents for signs and symptoms of influenza A, isolation of residents presenting with symptoms of influenza A, and post signage at the facility entrances to notify visitors of active illness in the facility. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility when 8 of 38 residents (R31, R11 , R36, R32, R38, R7, R35, R3) contracted influenza A. This resulted in an immediate jeopardy (IJ) which placed all 38 residents at a high likelihood for serious illness and/or death by contracting a communicable disease, including but not limited to influenza A. In addition, the facility failed to track and trend all resident actual/potential infection on the monthly tracking form to effectively identify symptoms and reduce the spread of infection with a potential to affect all 38 residents residing in the facility. The IJ began on 2/13/25, when R34 exhibited symptoms of respiratory illness, was not isolated or placed on TBP when symptoms were exhibited, and subsequently tested positive for influenza A on 2/14/25, and failed to implement interventions to reduce the spread of influenza A which resulted in eight other residents contracting influenza A. The director of nursing (DON) was notified of the IJ on 2/24/25, at 9:27 p.m. The IJ was removed on 2/26/24, at 10:26 a.m. when the facility implemented actions to reduce/prevent the spread of illness. 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: INFLUENZA A OUTBREAK: The Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities from the Centers of Disease Control (CDC) dated 9/17/24, identified influenza can be introduced into a long-term care facility by newly admitted residents, healthcare personnel, and visitors. Spread of influenza can occur between and among residents, healthcare personnel and visitors. Residents of long-term care facilities can experience severe and fatal illness during influenza outbreaks. If one laboratory-confirmed influenza positive case was identified along with other cases of acute respiratory illness in a unit of a long-term care facility, an influenza outbreak might be occurring. Active surveillance for additional cases should be implemented as soon as possible once one case of laboratory-confirmed influenza is identified in a facility. When 2 cases of laboratory-confirmed influenza were identified within 72 hours of each other in residents on the same unit, outbreak control measures should be implemented as soon as possible. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. The CDC guidance for Flu and People 65 Years and Older dated 9/5/24, identified people 65 years and older are at higher risk of developing serious flu complications compared with young, healthy adults. This increased risk is due in part to changes in immune defenses with increasing age. While flu seasons vary in severity, during most seasons, people 65 years and older bear the greatest burden of severe flu disease. In recent years, for example, it ' s estimated that between 70 percent and 85 percent of seasonal flu-related deaths have occurred in people 65 years and older, and between 50 percent and 70 percent of seasonal flu-related hospitalizations have occurred among people in this age group. On 2/24/25, at 11:30 a.m. surveyors entered the facility to conduct an annual recertification survey. No signs were posted to alert visitors an influenza outbreak was occurring in the facility. During the entrance conference 2/24/25, at 12:26 p.m. with the DON, the DON failed to identify there were any residents ill with respiratory illness or the facility may be experiencing an influenza outbreak. R34: R34's significant change Minimum Data Set (MDS) dated [DATE], identified R34 was [AGE] years of age and had moderately impaired cognition. R34 required maximum assistance with most activities of daily living (ADLs). R34 was vaccinated for influenza on 10/11/24. Diagnoses included Alzheimer's disease, acute kidney failure and encephalopathy. R34's progress notes identified on 2/12/25, R34 had developed a hoarse voice and dry cough and on 2/13/25, R31 had developed a low-grade temperature. A positive influenza test was identified on 2/14/25. Droplet precautions were put into place on 2/14/25. R34's medical record failed to identify transmission-based precautions were implemented when R34 first presented with respiratory symptoms to prevent the spread of influenza A to other residents and staff. R31: R31's quarterly MDS dated [DATE], identified R31 was [AGE] years of age and had intact cognition. R31 required partial assistance with dressing and was dependent with toileting and bathing. R31 was vaccinated for influenza on 10/10/24. Diagnoses included congestive heart failure, and diabetes. R31's progress note on 2/23/25, identified R31 complained of not feeling well with body aches and wheezes noted in both lung fields. R31 was sent to the emergency room to be evaluated and returned on 2/24/25, at 2:20 a.m. with a positive influenza A test result. R31's medical record failed to identify droplet precautions were implemented when R34 returned from the hospital positive for influenza A, to prevent the spread of influenza A to other residents and staff. On 2/24/25, at 3:20 p.m. prior to the surveyor entering the room for screening nursing assistant (NA)-A stated R31 was on enhanced barrier precautions because R31 had a catheter in place. Staff were required to wear gown and gloves when providing close contact care. The personal protective equipment (PPE) was not required to visit with resident if not in close contact with resident. The surveyor proceeded to enter the room to complete the screening process for the survey. On 2/24/25, at 4:46 p.m. trained medication aide (TMA)-A was observed removing the enhanced barrier precaution sign on R31's door and placing a droplet precaution sign on the door. During interview on 2/24/25, at 4:46 p.m. TMA-A stated R31 only had enhanced barrier precautions sign on his door, which directed staff to gown and glove when providing personal care and did not require staff to mask. TMA-A had just put a new droplet precaution sign on R31's door that directed all persons to gown, glove, and mask prior to entering the room. TMA-A stated all the staff working that day were aware R31 had tested positive for influenza A since his return from the emergency room at 2:30 a.m., as it was reported during shift report that morning. The precautions sign had just not been changed. (the droplet precautions were placed 13 1/2 hours later) When interviewed on 2/24/25, at 4:59 p.m. the infection preventionist registered nurse (RN)-A stated R31's precautions should have been changed from enhanced barrier precautions to droplet precautions as soon as he returned from the emergency department. R11: R11's admission MDS dated [DATE], identified R11 was [AGE] years of age and had severe cognitive impairment. R11 required moderate assistance with dressing, bathing, and toileting. R11 was vaccinated for influenza prior to his admission to the facility. Diagnoses included malignant neoplasm of the rectal sigmoid junction and thrombocytopenia. R11's progress note(s) identified on 2/24/25, R11 had required administration of acetaminophen 650 milligrams at 7:54 a.m. for a temperature of 101.4. On 2/24/25, at 1:13 p.m. a family member (FM)-A was observed sitting on R11's bed, in very close contact with R11, who was seated in his recliner in his room. FM-A stated R11 had a temperature that morning and had fallen getting out of bed as he was so weak. The facility had tested him for respiratory illness and were waiting on the results. FM-A was not wearing any PPE and there was no evidence transmission-based precautions were not implemented with close contact with R11. During observation on 2/24/25, at 1:20 p.m. two unidentified nursing assistants (NA) were seen entering R11's room to assist his roommate R14 to bed. R11 was seated in his recliner in the room, next to the fully open privacy curtain. The NAs drew the privacy curtain halfway across the room and assisted R14 to bed using a mechanical lift. The NAs re-opened the privacy curtain, used alcohol-based hand rub on their hands after completing the task and exited the room. Neither NA's put on personal protective equipment. There was no signage or PPE cart outside of R11's room to alert staff to the need for PPE when entering the room to prevent potential transmission to others. On 2/24/25, at 6:18 p.m. NA-C and NA-D were observed assisting R11 to the bathroom. NA-C, wearing mask and gloves, was kneeling in front of R11 who was seated on the toilet. NA-D was outside of the bathroom making the bed up. NA-D did not have gown or mask on. NA-D stated she remembered someone mentioning something about wearing a mask but had forgotten. NA-D exited the room to read the precaution sign posted on R11's room door. The sign indicated R11 was on droplet precautions, and everyone must wear a mask and clean hands on entering and leaving the room. If contact with secretions were likely staff were directed to use gown, gloves and eye cover as well. NA-D stated she now realized she needed to wear a gown and mask. NA-D put on a gown and surgical mask and brought NA-C an isolation gown to put on. R11's progress note on 2/24/25, at 6:31 p.m. identified R11 tested positive for influenza A and was placed on droplet precautions. Appropriate signage and a PPE cart were placed outside of his door. R22: R22's admission MDS dated [DATE], identified R22 was [AGE] years of age and had severe cognitive impairment. R22 required supervision with ADL's. R22 had not been vaccinated for influenza virus. Diagnoses included neurocognitive disorder with Lewy bodies, and heart disease. During observation on 2/24/25, between 1:00 p.m., to 5:30 p.m. R22 was lethargic, lying halfway on his bed with both feet on the floor. R22 did not wake to eat lunch. At 2:00 PM. TMA-A and another unidentified staff member were attempting to arouse R22 to drink water. Neither staff were wearing any PPE. There were no isolation precautions or PPE cart noted in the room. R22's progress note(s) identified the following: - 2/24/25, at 11:09 a.m. a respiratory panel was completed for cough, headache and body aches. - 2/24/25, at 2:02 p.m. identified R22 had been wandering throughout the shift, into other resident rooms and was difficult to redirect. - 2/24/25, at 7:20 p.m. identified R22 had not been feeling well that day and had complained of ear pain, neck pain and headache R22 had a temperature of 100.4 and oxygen saturation was 92%. A respiratory panel had been completed with results pending. R22 was sent to the emergency room for further evaluation. - 2/25/25, at 3:21 a.m. identified R22 had returned from the emergency room. R22's respiratory panel was negative, however, R22 continued to complain of neck pain, refused to eat his meals and remained in bed. R22's medical record failed to identify transmission-based precautions were implemented when R22 first presented with respiratory symptoms on 2/24/25, to prevent the spread of potential respiratory infections to other residents and staff. R36: R36's admission MDS 12/11/24, identified R36 was [AGE] years of age and had intact cognition. R36 was independent with his ADLs. R36 had been vaccinated for the influenza prior to his admission to the facility. Diagnoses included chronic obstructive pulmonary disease, irritable bowel syndrome, and abnormal weight loss. During interview on 2/24/25, at 2:51 p.m. R36 stated he was not feeling well and had not eaten much in two weeks. R36 reported he had fallen that morning because he was so weak. There were no isolation precautions, signage or PPE cart noted in the room. On 2/24/25, at 3:28 p.m. R36 was observed dressed in coat, hat and gloves, ambulating down the hallway. R36 stated he was going outside to smoke a cigarette. R36 stopped at the nurse's station and visited with the nurse for several minutes, before obtaining a cigarette and going outside to smoke. R36's progress note dated 2/24/25, at 7:42 p.m., identified R36 had tested positive for influenza A and was placed on droplet precautions. R32: R32's quarterly MDS dated [DATE], identified R32 was [AGE] years of age and had intact cognition. R32 was independent with ADL's. R32 had refused the influenza vaccine. Diagnosis included chronic obstructive pulmonary disease. R32's progress note(s) identified the following: - 2/23/25, R32 complained of chest congestion and had a temperature of 101.2. - 2/24/25, R32 was positive for influenza A and placed on droplet precautions. R32's medical record failed to identify transmission-based precautions were implemented when R34 first presented with respiratory symptoms on 2/23/25, to prevent the spread of influenza A to other residents and staff. During observations on 2/24/25, there continued to be no signs posted on the facility entrances to inform visitors and staff of influenza in the building. When interviewed on 2/24/25, at 6:10 p.m. RN-A stated when residents exhibit a cough or elevated temperature the facility encouraged the resident to stay in their room. If the resident needed to come out of their room, they were encouraged to wear a surgical mask and did not implement transmission-based precautions. The facility did not implement droplet precautions unless the resident had a positive test result for influenza. During interview on 2/24/25, at 6:29 p.m. the director of nursing (DON) stated R34 was the facility's first case of confirmed influenza. R34 tested positive for influenza A on 2/13/25 and was placed on droplet precautions on 2/14/25 and not when R34 first developed symptoms. When residents did not feel well, the facility tried to limit exposure to the ill resident until they had confirmed test results. R31 tested positive for influenza A during his visit to the emergency room and should have been isolated and placed on precautions on his return. The DON indicated she thought six other residents had some symptoms of respiratory illness and had been tested. The residents were not on transmission- based precautions but were asked to stay in their rooms as much as they could. Staff and visitors were not required to wear PPE to enter the resident rooms and some of the symptomatic residents did share their room with a roommate. The DON stated residents who exhibited any symptoms of respiratory illness should be placed in transmission based-precautions, a respiratory test completed and then placed in droplet precautions with a confirmed test however, the documentation did not reflect that. When interviewed on 2/24/25, at 7:33 p.m. the DON stated the facility was now implementing droplet precautions with all residents who exhibited symptoms of acute illness and not waiting for lab results before implementing the precautions. However, the facility was not doing any active surveillance for monitoring for influenza A and only obtained vital signs including temperatures weekly unless they report symptoms of illness or the facility staff notice something was off. Further, the facility had not done anything different with roommates of residents with influenza A such as isolating them or offering room changes. The DON felt when they did that during the COVID pandemic and felt it did not work and spread the illness further. During an interview on 2/26/25 at 3:41 p.m., RN-A stated she was responsible for the facility Infection Prevention and Control Program. RN-A started her role at the facility in November 2024 and worked as the facility's wound nurse as well. Staff would document any signs/symptoms of possible infections in the resident electronic medical record (EMR) and staff had the ability to initiate transmission-based precautions but had not done so until RN-A arrived to work on 2/24/25. Any resident with any sign or symptoms of infection should have been documented on the surveillance log to prevent the spread of illness. Further, the facility had not started active surveillance of residents to identify symptoms early. The facility identified via email R38 ,R7, R35 and R3 had subsequently positive influenza A tests: R38's admission MDS dated [DATE], identified R38 was [AGE] years old and had diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis and hemiplegia (weakness of one side of the body) following a stroke and hypertension. R7's quarterly MDS dated [DATE], identified R7 was [AGE] years old and had diagnoses that included chronic obstructive pulmonary disease (COPD) (a lung condition caused by damage to the airways and alveoli), asthma and hypertension. R35's quarterly MDS dated [DATE], identified R7 was [AGE] years old and diagnoses that included hypertension and type 2 diabetes. R3's quarterly MDS dated [DATE], identified R3 was [AGE] years old and had diagnoses that included atrial fibrillation (irregular heartbeat), heart failure and chronic kidney disease. The facility Influenza A and B or Lung MDRO policy dated 9/11/17, identified in addition to standard precautions, staff were to implement droplet precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking or by the performance of procedures such as suctioning. If the resident's cognition and physical ability was such that they were consistently able to cover their cough and place the tissue in a trash bag, they could come out of their room and have company without wearing a mask. The resident must be able to follow instructions and do proper hand hygiene. Place resident in a private room. if private room was not available and cohorting was not achievable, staff were directed to use curtain in room and maintain at least three feet of space between infected resident and other residents or visitors. In addition to standard precautions, staff were to wear a mask when working within three feet of the resident. The facility Resident Influenza policy dated 5/1/24, identified influenza was a highly contagious infection of the respiratory tract caused by a virus and transmitted by air-borne droplet infections. Typical influenza illness was characterized by abrupt onset of fever/chills, myalgia, sore throat and non-productive cough. Staff were instructed to report to the charge nurse or infection prevention any suspicion of residents exhibiting influenza symptoms. Employees with a fever of 100.4 or higher should not come to work. use proper handwashing techniques, use appropriate PPE when caring for residents with symptoms of influenza. any resident with influenza symptoms or fever over 100.4 must eat in their room. Keep resident away from activities or therapies if contagious and discourage visitors. All cases of influenza would be entered on the facility infection control logs. The IJ that began on 2/13/25, was removed on 2/26/25, at 10:26 a.m., when it could be verified through observation, interview and document review the facility implemented droplet precautions for all residents that tested positive for influenza A, implemented a system for ongoing active surveillance of residents for symptoms of influenza A, implemented transmission -based precautions for all symptomatic residents until confirmatory test resulted and the facility reviewed and revised their influenza policy to reflect current CDC guidelines.