**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 Respiratory Syncytial Virus (RSV- an infection of the respiratory tract). As a result, the facility developed an outbreak where 8 residents (R10, R13, R14, R11, R12, R17, R6, and R16) tested positive for RSV and 3 residents were suspected to have RSV (R15, R7, R18); 2 residents (R10 and R12) were seen in the emergency department (ED) and 3 residents (R11, R13, and R14) were hospitalized at a higher level of care. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility resulting in an immediate jeopardy (IJ) which placed all residents at a high likelihood of serious illness and/or death by contracting a communicable respiratory disease. The Immediate Jeopardy (IJ) began on 3/23/25 when R10 tested positive for RSV and the facility failed to implement infection control strategies to mitigate the risk and spread of RSV in the facility. The Administrator and director of nursing (DON), were notified of the IJ on 4/4/25 at 3:30 p.m. The IJ was removed on 4/8/25 at 6:32 p.m., but noncompliance remained at the lower scope and severity level F, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: Definitions: Isolation: Isolation separates sick people with a contagious disease from people who are not sick. Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. Personal protective equipment (PPE): Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. These items may include a gown, gloves, eye protection and face mask. Enhanced barrier precautions (EBP): refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Gowns and gloves are used as PPE. Transmission based precautions (TBP): refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) to prevent or control infections. Airborne, contact, and droplet are the three subcategories under TBP. Contact precautions: refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Use with gloves, and gowns as PPE. Droplet precautions: refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions, masks are used as PPE. Upon entrance to the facility on 4/1/25 at 11:15 a.m., there was no signage posted alerting that the facility had an RSV outbreak. Surveyor was informed the facility had one case of RSV in the building and resident (R12) was on precautions. This was observed on 4/1/25 at 11:54 a.m., of the south hallway with signage on R12's door. Trained medication aide (TMA)-F was using PPE when entering the room to administer medications. R10 symptom onset 3/16/25; positive RSV on 3/16/25 R10's face sheet dated 4/11/25, identified diagnoses of morbid (severe) obesity with hypoventilation, obstructive sleep apnea, heart failure, chronic obstructive pulmonary disease (COPD- lung diseases that cause persistent airflow obstruction and breathing difficulties). R10's record reviewed between 3/11/25 through 3/15/25 did not identify any symptoms of respiratory illness. R10's progress note dated 3/16/25 at 12:45 p.m., indicated R10 stated he was not feeling well and thinks he has COVID. Lung sounds with noted rhonchi (rattling lung sounds). COVID test performed with negative results. R10's medical record did not identify R10 was placed on isolation precautions (droplet/contact precautions) when respiratory symptoms were identified. R10's record did not indicate droplet/contact precautions were initiated at symptom onset. R10's progress notes dated 3/16/25 at 1:22 p.m., indicated R10 had not been feeling well for four days with coughing. R10's lung sounds with rhonchi and cough and R10 agreed to be sent to emergency department (ED). R10's hospital emergency department (ED) note dated 3/16/25, identified R10 was seen for evaluation for an ongoing cough over past few weeks and increasing shortness of breath. R10's ED record identified lung sounds to be diffuse rhonchi (sounds like snoring or gurgling) throughout and tested positive for RSV. R10's diagnoses at discharge from the ED included RSV bronchiolitis (swelling, irritation, and buildup of mucus in the small airway of the lung) and acute exacerbation of COPD. R10 discharged back to the facility with nebulizers and steroids. R10's progress note dated 3/16/25 at 4:56 p.m., identified paperwork from hospital reviewed and R10 diagnosis of RSV and COPD exacerbation. Staff updated on airborne (sic) precaution, reminded to wear masks, gloves, and wash hand. However, review of R10's record did not identify a physician order for precautions nor was TBP identified in R10's care plan. R10's record reviewed between 3/17/25 through 4/4/25 did not identify ongoing symptom monitoring, isolation, transmission precautions, or removal of isolation. During an interview on 4/3/25 at 11:12 a.m., director of nursing (DON) stated if a resident is positive for RSV they are put on precautions and isolation and encouraged to wear a mask when coming outside of their room. DON stated they did not have any protocols for nurses to follow for monitoring residents for any symptoms to identify new cases immediately. DON confirmed facility had not done any active screening of residents to identify illness and had not completed comprehensive respiratory assessments for residents with suspected/confirmed RSV cases. During a subsequent interview on 4/4/25 at 11:11 a.m. DON confirmed R10 was removed from isolation on 3/23/25, R10 did not have a respiratory assessment to determine if symptoms resolved prior to removing from isolation, R10 was removed from isolation because he no longer needed nebulizer treatments. DON further stated after research on the Centers for Disease Control and Prevention (CDC) website for RSV, a resident should have been in isolation and precautions for ten days, however, the facility did not follow CDC guidelines and removed R10 at seven days. R13 symptom onset 3/25/25; positive on 4/3/25 R13's face sheet date 4/10/25, indicated diagnoses of dementia and weakness. R13's record between 3/16/25 through 3/26/25 did not identify any respiratory symptom screening, even though the facility had RSV cases. R13's progress note dated 3/27/25, identified R13 complained of sore throat for two days. R13 was given cough drop and COVID test performed with negative results no other tests were completed. R13's progress noted dated 3/30/25, identified R13 received cough syrup for cough. R13's progress note dated 4/2/25 at 12:37 a.m., identified R13 was coughing with congestion and feeling cold/chills. At 3:56 p.m. R13 was feeling weak and complaining not feeling good. Lung sounds wheezing with crackles was coughing with congestion and feeling cold and chills. R13 was given a nebulizer with no relief. R13 was placed on oxygen. Physician notified of change in condition and recommendation to monitor in facility and will reassess next day. R13's progress note dated 4/3/25 at 9:50 a.m., identified R13 became short of breath (SOB) while on toilet and unable to stand. Oxygen was placed on R13 and given a nebulizer with oxygen saturations going as low as 80% (normal ranges are 92 to 100%). Provider was notified. At 10:28 a.m. R13 was seen by the nurse practitioner who ordered RSV test, antibiotics, and steroids. At 10:59 a.m. R13 was short of breath with low oxygen saturations and was sent to the ED. R13's record between 3/25/25 through 4/3/25, identified despite R13 demonstrated respiratory symptoms TBP was not implemented. During an observations on 4/1/25 through 4/3/25 at 11:00 a.m., R13 did not have TBP precaution signs on his door. During an observation and interview on 4/3/25 at 11:00 a.m., trained medication aide (TMA)-D came out of R13's room without PPE and stated R13 was being sent to ED due to difficulty breathing and possible RSV. TMA-D stated R13 had been sick since 3/30/25, and he complained of a sore throat and was not put on precautions or isolation when he developed symptoms. During an interview on 4/3/25 at 11:21 a.m., registered nurse (RN)-B stated R13 was sent by ambulance for possible RSV. RN-B stated R13's roommate, R14 was in the hospital for unknown reason. RN-B also stated the facility had three known cases of RSV, R10, R11 and R12. RN-B stated R12 was the only resident currently on isolation for RSV in the facility. RN-B stated if a resident became symptomatic a comprehensive respiratory assessment should be completed daily, however a nursing order was not in the charts to direct staff on what to monitor for. RN-B further stated symptomatic residents should be put on droplet precautions, notify physician, and tested for RSV. R13's ED hospital record dated 4/3/25, indicated R13 was seen in ED for shortness of breath. R13 required supplemental oxygen to maintain oxygen level greater than 92%. R13 indicated that he had not been feeling well for the past 3 weeks. R13 lung sounds revealed right and left wheezing through with decreased lung sounds in right middle and bilateral lower fields. R13's heart rate was 90-150 (normal range is 60 - 100) with no known history of atrial fibrillation. R13 was admitted to the local hospital and started on intravenous antibiotics (IV) and IV cardiac medications were started also. R13 tested positive for RSV and was transferred to higher level of care for further care with diagnoses of respiratory failure, sepsis, and Atrial fib with rapid ventricular response. R13 returned to the facility on 4/7/25, with hospital diagnoses of pneumonia of right lower lobe due to infectious organism and was started on oral antibiotics. R14 symptom onset 3/25/25, positive for RSV on 4/1/25 R14's face sheet dated 4/10/25, indicated diagnoses of CHF and chronic respiratory failure with hypoxia. R14's record between 3/16/25 through 4/1/25 did not identify any respiratory symptom screening, even though the facility had RSV cases. R14's progress notes dated 3/8/25, identified R14 required continuous oxygen to keep saturations greater than 90%. R14's progress notes dated 3/25/25, identified R14 had complaints of not being able to breathe from his nose being stuffy, however R14's medical record did not identify implementation of TBP when symptoms identified. R14's progress notes dated 4/1/25, R14 received two puffs of albuterol inhaler (medication to help open airway) as R14 was struggling to breathe, wheezing and had congestion. R14 had chills and was shaking. Vital signs were blood pressure 155/104 (normal is less than 120/80), pulse 105, respirations 22 (normal range is 12-22) and oxygen saturations 72% on three liters of oxygen. R14 was transported to local ED via ambulance. R14's hospital ED note dated 4/1/25, indicated R14 presented per ambulance, unresponsive after sudden onset of shortness of breath. R14's lung sound indicated chest lung congestion bilaterally with mottling (bluish/graying skin color meaning lack of oxygen). R14 was intubated emergently (a tube is inserted into the trachea to help person breathe). R14's temperature was 103 degrees (normal is 96.4 to 98.6). R14 was tested positive for RSV and was transferred via air ambulance to higher level of care with diagnoses of septic shock (a life-threatening condition) and acute respiratory failure. R14's hospital pulmonology noted dated 4/2/25, identified R14 was on mechanical ventilation and had a diagnosis of acute on chronic hypoxemic hypercapnic respiratory failure -improving and RSV pneumonia complicated by left lower lobe pneumonia. R14's progress notes dated 4/3/25, identified social worker at hospital called and R14 was sedated, on a ventilator, and positive for RSV. R14's hospital note dated 4/9/25, R14 remained at a higher level of care, on three liters of oxygen, with no return dated noted. During an interview on 4/3/25 at 1:00 p.m., DON stated R14 was in the hospital for aspiration pneumonia but had been negative for RSV. During an interview on 4/4/25 at 10:58 a.m., assistant director of nursing/infection preventionist (ADON -IP) stated she was not aware of R14's positive RSV test result until 4/3/25 after looking at the hospital records. ADON-IP stated R14's onset of RSV began on 4/1/25 with the positive test and was unaware of symptom onset of a stuffy nose on 3/25/25. R11 symptom onset 3/28/25, positive 3/28/25 R11's face sheet dated 4/10/25, indicated diagnoses of congestive heart failure (condition where heart does not pump as well as it should), respiratory failure (condition where the lungs are unable to adequately exchange gases, resulting in either insufficient oxygen intake and/or inadequate carbon dioxide removal) with hypoxia (lack of oxygen), and morbid obesity. R11's record between 3/16/25 through 3/28/25 did not identify any respiratory symptom screening, even though the facility had RSV cases. R11's record did not identify R28 had symptoms prior to 3/28/25. R11's progress note dated 3/28/25 at 1:32 p.m., identified R11 was not feeling well after 12:00 p.m., and appeared to be shaky, unable to transfer self, and needed supplemental oxygen, and 911 was called. Note at 2:16 p.m., identified R11 was transferred to hospital via ambulance. R11's progress note dated 3/28/25 at 4:44 p.m., identified hospital called and R11 had tested positive for COVID and RSV. R11's hospital ED note dated 3/28/25, indicated R11 presented via EMS for evaluation of difficulty breathing, shaking, nausea, tachycardia, and low blood pressure. Heart rate in 140's with oxygen sats in the 70's and temperature of 100.4. R11's lung sounds were decreased with wheezing and rales present. R11 was transferred to higher level of care due to hypoxia secondary to new diagnosis of RSV and COVID. R11's progress notes dated 4/7/25, indicated R11 remained in ICU, was hallucinating, and was restless and needing supplemental oxygen at 4 liters per nasal cannula. R12 symptom onset 3/31/25, positive 3/31/25 R12's face sheet dated 4/10/25, indicated diagnoses of cancer of the prostate, CHF and dementia. R12's record between 3/16/25 and 3/30/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 3/31/25. R12's progress notes dated 3/31/25, indicated R12 was showing decline in health, slightly diaphoretic (sweaty) and slightly elevated blood pressure. R12 was sent to ED for evaluation. R12's ED progress notes dated 3/31/25, indicated R12 was seen in ED following a fall and had mentation changes. R12 had a cough and nursing home staff reported increased lethargy. R12's assessment indicated a congested cough with rhonchi (abnormal lung sounds caused by secretions or obstruction of airway) in left lower lobe. R12 tested positive for RSV in ED and was discharged back to the nursing home by private vehicle. R12's progress note dated 3/31/25 at 3:01 p.m., identified R12 returned to facility with a diagnosis of RSV. R12's record did not identify if and when TBP were implemented after return from ED. R12's progress notes from 3/31/25 through 4/8/25 lacked an ongoing symptom monitoring and utilization of TBP. During an observation on 4/1/25 at 5:07 p.m., R12 was noted in the hallway outside conference room without a mask on. Three staff walked by him. Nursing assistant (NA)-P stopped, applied gloves, and turned R12's wheelchair around, explained to R12 he needed to stay in his room as he was sick. NA-P was not wearing a mask and did not apply or offer one to R12 as he took him back to his room. During an observation on 4/3/25, at 5:12 p.m., approximately 15 residents were eating in the main dining room, 3-5 residents per table, without masks on. Resident were seated two to three feet apart. R12, who was RSV positive on 3/31/25, was seated a few feet from R15, neither one had mask on. Multiple staff were in the dining room, serving the meals and did not identify R12 should have been eating in his room. DON entered dining room and applied a mask to R12 and walked him out to his room from the main dining room. DON stated R12 should have been eating in his room and not in the main dining room. During an interview on 4/3/25 at 5:25 p.m., NA-H stated R12 was supposed be eating in his room due to RSV, and if staff noticed him coming out of his room, staff walked him back to his room. During an interview on 4/4/25 at 10:58 a.m., ADON-IP stated she was not employed in the facility when the first case of RSV was detected and had not implemented contact tracing since she had started, however had started a map of the positive cases. ADON was not aware how many cases constituted an outbreak, but thought it was three or more. R12, R13, and R14 all ate meals together and she believed this was part of the spread and had just made that determination today on 4/4/25. If residents were exposed to another positive resident who had RSV they should have been kept in isolation, monitored closely for symptoms, and tested if symptoms develop. R17 symptom onset 4/4/25; positive for RSV on 4/9/25 R17's face sheet dated 4/10/25, indicated diagnoses of diabetes, paraplegia (paralysis of the legs and lower body), and diabetes. R17's record between 3/16/25 through 4/7/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/4/25. R17's progress note dated 4/4/25, R17 had reported he did not feel good but was not ill. R17's record did not include respiratory assessments until 4/8/25. R17's record did not identify a respiratory assessment/screener between 4/5/25 to 4/7/25. R17's progress note dated 4/8/25, indicated R17 had cough with congestion. However, the record indicated R17 was not tested for respiratory illness until 4/9/25. R17's laboratory report dated 4/9/25, indicated R17 tested positive for RSV. R6 symptom onset 4/6/25; positive for RSV on 4/9/25 R6's face sheet dated 4/10/25, indicated diagnoses of cerebrovascular accident (stroke), hemiplegia or hemiparesis (weakness on one side of the body). R6's record between 3/16/25 and 4/5/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/6/25. R6's progress note dated 4/6/25 at 8:45 p.m., R6 requested an RSV test as he was having a sore throat and raspy voice. R6's progress note dated 4/8/25, identified R6 was on quarantine due to unspecified outbreak. R6's progress notes dated 4/9/25, identified lab results received by facility and tested positive for RSV. R16 symptom onset 4/7/25; positive for RSV on 4/9/25 R16's face sheet date 4/10/25, indicated diagnoses of CHF, Parkinson's Disease (a progressive neurological disorder characterized by gradual loss of nerve cells in the brain, leading to tremors, slow movements, and rigidity), obstructive sleep apnea, myasthenia gravis an autoimmune disorder) and respiratory failure. R16's record between 3/16/25 and 4/6/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/7/25. R16's progress note on 4/7/25 identified R16 had developed a cough with wheezing. R16 was placed on precautions and tested. R16's laboratory results dated [DATE], indicated R16 tested positive for RSV. R15 symptom onset 4/7/25 R15's face sheet dated 4/10/25, indicated diagnoses of chronic viral hepatitis C and sheltered homelessness. R15's record between 3/16/25 and 4/6/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/7/25. R15's progress note 4/7/25, identified R15 had developed sore throat. R15's laboratory report dated 4/9/25, indicated R15 tested negative for RSV, COVID and influenza. R7 symptom onset 4/8/25 R7's face sheet dated 4/10/25, indicated diagnoses of multiple sclerosis (MS- a chronic autoimmune disease that affects the brain and spinal cord). R7's record between 3/16/25 and 4/7/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/8/25. R7's progress notes dated on 4/8/25, R7 had developed a sore throat, and hoarse voice. R7's laboratory results dated [DATE], indicated R7 tested negative for RSV, COVID and influenza. R18 symptom onset 4/8/25 R18's face sheet dated 4/10/25, indicated diagnoses of obstructive sleep apnea. R18 ' s record between 3/16/25 and 4/7/25 did not identify any respiratory symptom screening and did not have symptoms of illness prior to 4/8/25. R18's progress notes dated 4/8/25, R18 was noted to be coughing, stated it was his normal and respiratory assessment completed without any other symptoms noted. R18 was put on droplet/contact precautions, however refused to be tested for COVID, influenza and RSV. During an interview on 4/4/25 at 8:57 a.m., licensed practical nurse (LPN)-B stated monitoring for respiratory symptoms would include lung sounds, looking for symptoms like runny nose or cough. If new symptoms were found then the provider would be notified, the resident tested, and precautions put into place. LPN-B was not aware of any symptom monitoring being done for any residents at this time and this should be done. During an interview on 4/3/25 at 3:24 p.m., registered nurse (RN)-B stated if staff call in sick with respiratory symptoms, they would be asked to test for COVID, however, if negative then it must just be a cold, and could work while wearing a mask. If a resident became symptomatic then staff would test and monitor symptoms, however, was not aware if the facility was doing that. RN-B stated she believed full facility masking and monitoring of all the residents for symptoms of RSV should have been initiated after the first case of RSV was in the facility. During an interview on 4/3/25 at 1:00 p.m., DON stated if there was a respiratory outbreak, the following would need to be initiated: staff masking, encourage resident masking, reduce the number of residents in activities, and limit numbers in dining room for meals. However, none of these activities had been done at this time, due to not identifying the cases of RSV as an outbreak. DON also stated not all the RSV cases had been added to a surveillance log to track the cases. DON stated a map of the cases in the facility had not been completed at this time to allow the facility track trend the infection. Staff illness was tracked, and no cases of respiratory illness had been identified. During an interview on 4/4/25 at 10:31 a.m., medical director (MD)-A stated was not aware of the facility's RSV outbreak until 4/3/25. His expectations during a respiratory outbreak would be for the facility to follow their policies on infection control/respiratory illnesses, notify the medical director, and follow recommendations from CDC/MDH on TBP. Any type of respiratory illness with a resident with other contributing factors, such as COPD, could lead to the likelihood of serious harm, impairment, or even death. The immediate jeopardy that began on 3/16/25, was removed on 4/8/25. when it was verified, the facility implemented the following: -Facility provided education to all staff pertaining to PPE, implementation and removal of TBP, physician notification, active screening, and staff illness. -Facility updated the surveillance log -Facility implemented and developed a tracking log for staff illness. -Facility developed screening and monitoring tools for respiratory illnesses. -Facility developed and implemented a process for implementing and removing TBP's and physician notification. -Facility developed and implemented a process for testing residents. -Facility identified high risk exposures to RSV and placed those residents on isolation, -Facility implemented active screening on all residents to identify early symptoms and implemented TBP as applicable. -Implemented mask use for staff and visitors. -Facility provided education to all staff pertaining to PPE, implementation and removal of TBP, physician notification, active screening, and staff illness. -Facility updated the surveillance log -Facility implemented and developed a tracking log for staff illness. Review of facility's Infection Outbreak Response and Investigation Policy undated, identified an outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. Prompt recognition of an outbreak: The following triggers shall prompt an investigation as to whether an outbreak exist: -A sudden cluster of infections in a unit or during a short period of time. -A single case of a rare or serious infection. Implementation of infection control measures: -symptomatic residents will be considered potentially infected, assessed for immediate need, and placed on empiric precautions while awaiting physician orders. -symptomatic employees will be screened by the Infection Preventionist/or designee. -In the event of a known communicable disease outbreak, the facility should screen visitors for signs and symptoms of the communicable disease in accordance with national standards. -Transmission based precautions will be implemented as indicated for the particular organism. -Surveillance activities will increase to daily for the duration of the outbreak. Outbreak investigation: -Last page was not provided Review of facilities undated and unsigned, Transmission Based (Isolation Precautions) Type and Duration of transmission-Based Precautions Recommended for Selected Infections and Conditions, chart dated 2024, indicated for RSV infection in immunocompromised adults, contact precautions was needed for duration of illness and to wear a mask according to standard precautions. Review of facility policy, dated 3/24/25, Infection Prevention and Control Program, indicated the following: 3. Surveillance: a. a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteer, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. c. The registered and licensed practical nurses participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in house reporting of communicable diseases and infections. 13. Resident/Family/Visitor Education and Screening a. Residents, family members and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and conditions for which to notify the nursing staff. 19. Respiratory Illness Reporting: a. The facility must input the following information into the NHSN reporting module weekly: 3. confirmed resident cases of COVID 19, influenza, and RSV; 4. hospitalized residents with confirmed cases of COVID 19, influenza, and RSV (overall and by vaccination status).